Policymakers at the state and federal level should remove regulatory barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and lead primary care teams, according to a report that recommends changes to primary care in the United States.
The report from the Josiah Macy Jr. Foundation, based in New York City, also calls for more interprofessional education so physicians, nurses, and physician assistants can learn what it's like to work in a team environment during training. The recommendations represent the consensus reached by experts who convened in Durham, N.C., to discuss primary care areas in need of reform, from medical education to the physician payment system.
“Everyone agreed that there is great urgency to act now,” Dr. George E. Thibault, president of the Josiah Macy Jr. Foundation, said at a press briefing held to release the report. “Whether or not certain aspects of health care reform are enacted, everyone agreed that we will need well-trained providers from multiple professions to meet the public's need. This must be a team effort.”
Although most of the advice in the report was praised, some physician organizations expressed concern about the idea of expanding the role of nurse practitioners and physician assistants. The American Medical Association, for example, said it was concerned about extending patient care responsibilities to medical professionals who are “not adequately educated and trained to perform them.”
“Primary care benefits from a team approach to care delivery, with every member of physician-led teams playing the roles they are educated and trained to play,” Dr. Rebecca J. Patchin, chair of the AMA's board of trustees, said in a statement. “Every patient should have access to a personal physician, and the AMA is committed to increasing the physician workforce by advocating for increasing medical school class sizes and adding additional residency slots.”
Dr. Michael S. Barr, vice president of practice advocacy and improvement at the American College of Physicians, said the ACP supports team-based care and training with other health professionals, but the expanded role for nurse practitioners and physician assistants goes a bit too far. A 2009 ACP policy paper on the role of nurse practitioners in primary care stated that a patient-centered medical home should have a multidisciplinary clinical team that is led by a physician. But the paper also stated that demonstration projects on the medical home could test the effectiveness of clinical teams led by nurse practitioners, provided they are in line with state practice laws.
“We're all in alignment in terms of training together the way we should practice. We're all supportive of primary care–oriented programs in all of our respective health professional training venues,” Dr. Barr, who participated in the consensus conference, said in an interview. “It's just that we still feel like the team is best led by a physician.”
The Macy Foundation report made several other recommendations:
▸ Create stronger relationships between academic health centers and primary care sites within their communities.
▸ Invest in health information technology for primary care that supports data sharing, quality improvement, clinical care, and patient engagement.
▸ Reform primary care payments by creating global payments linked to patient complexity, care coordination, chronic disease management, and 24/7 access.
▸ Expand scholarship and loan repayment programs for students pursuing careers in primary care.
▸ Promote early exposure to primary care practice for all medical, nursing, and other health professional students.