REBEKAH BERNARD MD (1)
The United States spends more on healthcare than comparable nations, with a spending gap that has markedly increased over the last forty years. However, this additional spending has not translated into better health outcomes for Americans, with the U.S. lagging behind other similar nations. While health policy experts and economists have written volumes analyzing the deficit between U.S. spending and health quality measures, one variable is always missing: the impact of nonphysician practitioners on U.S. healthcare.
Over the last fifty years, non-physician practitioners like nurse practitioners and physician assistants have increasingly assumed roles traditionally filled by physicians. Originally created in 1965 by physicians, these professions were specifically designed to bring primary medical care to underserved areas. Anticipating an impending physician shortage, the U.S. government strongly supported the growth of both professions, and by 1987, the federal government had spent $100 million on nurse practitioner training programs and passed legislation mandating that nonphysician practitioners comprise at last fifty percent of medical professionals in rural clinics.
In 2010, the Affordable Care Act further expanded the role of nurse practitioners, creating nurse-led clinics. By 2020, nearly half the states in the Union have granted nurse practitioners the right to practice independently without physician supervision, with North Dakota recently becoming the first state to grant physician assistants the same privilege.
In 2013, the U.S. ranked 24th of 28 countries in the number of practicing physicians, with only 2.56 physicians for every 1,000 people.
The only countries ranking worse than the U.S. were Canada (2.46 physicians per 1,000), Poland (2.24), Mexico (2.17), and Korea (2.16). For contrast, the top physician ratios occur in Austria (4.99 doctors per 1,000), Norway (4.31), Sweden (4.13), Germany (4.04), Switzerland (4.04), Italy (3.81), and Spain (3.69).
Not only do we not have as many physicians in the U.S. compared to other similar nations, but we also are not keeping up with the production of new doctors. While the U.S. has increased the number of medical schools by 28% since 2003, residency slots, the final required stage of physician training, have remained flat due to a cap in payment support from the government, which has been frozen into place since 1997. Because of a lack of funding of physician training, the United States ranks 30th out of 35 industrialized countries in producing medical school graduates, graduating only 7.26 new doctors per 100,000 population in 2013, compared with countries like Ireland, (20.13/100,000), Denmark (18.38), Australia (15.44), and Austria (14.85).
Unlike the rest of the developed world, rather than train more physicians, the U.S. has elected to utilize nonphysician practitioners, with 40.5 nurse practitioners and 40 physician assistants per 100,000 population. Studies have shown that these practitioners can provide safe and effective care—but only when treating low-risk patients and working under physician supervision or following physician-created protocols. No quality studies have ever been done to analyze care provided by non-physicians practicing independently, and yet across the nation, physicians are being replaced by non-physician practitioners.
What impact has this replacement had on patient health and cost?
Studies show that continuity of care with a regular physician is associated with lower rates of death. People who have a primary care doctor can expect to live 51.5 days longer over 10 years, due to lower rates of death from cardiovascular disease, cancer, and lung disease. Increasing the number of specialists by 10 physicians per 100,000 people is associated with a 19.2-day increase in life expectancy over ten years.
Physicians train for 15,000 hours before being permitted to treat patients, while nurse practitioners require a minimum of 500 hours and physician assistants a minimum of 2,000 hours. Can practitioners with a fraction of the training as physicians offer the same mortality reduction? We simply don’t know. However, what we do know should give us pause. We know that more people die worldwide from poor quality healthcare than die from a lack of healthcare. We know there has been a recent explosion in online training programs, including those which allow non-nurses to become nurse practitioners in as little as two years. While some of these programs have recently lost accreditation or are under investigation, graduates continue to provide medical care to unsuspecting patients.
We also know that the rapid growth of non-physician practitioners over the last forty years may be a factor in the rise in healthcare spending. Studies have also shown that nurse practitioners and physician assistants increase healthcare costs due to more utilization of health care resources, longer consultations and more follow-ups, increased clinical staff time, increased ordering of laboratory and radiology tests, unnecessary skin biopsies, more prescription medications, including unnecessary antibiotics, psychotropic medications, and opioids, and poorer quality of referrals to specialists.
These additional tests and procedures can add up. In 2013, the Institute of Medicine estimated that “unnecessary services” added $210 billion to healthcare spending in the U.S., making it the single biggest contributor to waste. Unfortunately, additional healthcare utilization can also result in large profits for corporations and private equity firms, who have been particularly quick to replace physicians with nonphysician practitioners—and patients often don’t have a choice in who provides their care when they visit these facilities.
Can these increased expenses be offset by lower salaries for non-physician practitioners? Not necessarily. An analysis in the United Kingdom found that employing a nurse practitioner is likely to cost as much or more than a primary care physician due to the increased amount of staff time required. While in the past, non-physician salaries were significantly lower than that of physicians, the pay difference has markedly narrowed, with non-physicians now advocating for ‘pay parity’—to be paid the same as their physician counterparts. The state of Oregon already requires that insurance companies pay nurse practitioners and physician assistants the same rates as physicians, and President Trump’s October 2019 Executive Order proposed regulation that would expand that legislation across the nation.
In addition to concerns over the replacement of physicians, increasing the number of nonphysician practitioners has also taken a toll on the critical health profession of bedside nursing, with the transition of nurses to nurse practitioners reducing the number of practicing registered nurses by 80,000 nationwide. Bedside nurses are crucial to the health and wellbeing of patients in hospitals and healthcare facilities across the country, and inadequate nurse staffing increases the risk of patients being harmed in the healthcare system.
Replacing physicians may also lead to increased healthcare costs due to medical errors, which are estimated to contribute $19.5 billion per year to healthcare spending,with poor-quality care ultimately costing Americans $750 billion per year. While physicians certainly have a role in medical errors, a review of malpractice data shows that claims for physicians have steadily declined since 2001, while nurse practitioner claims have nearly doubled in the last decade, with increasing indemnity rates per claim.
It’s time for health policy experts—and the public—to wake up and to begin to question whether or not replacing physicians with nonphysician practitioners is actually healthy for the state of our nation.
Rebekah Bernard MD is a family physician and the co-author of the new book Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.