The Evolving Role of the Midlevel Providers

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Edwina Holt
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1 The Evolving Role of the Midlevel Providers Sarah Sinclair Executive Chief Nursing Officer Stanley Shalom Zielony Institute for Nursing Excellence May 12, 2011

2 Overview Healthcare and the economy Workforce challenges Healthcare reform Role of the Mid-level Provider Perspectives from: - Physicians - Academics - Physician Assistants - Advanced Practice Nurses

3 Healthcare and the economy The shift in demand of medical services is a reality HC provides jobs across a wide-spectrum of occupational skill levels Those jobs are city-centric in older metropolitan areas Direct patient services is experiencing rapid restructuring with new organizational forms Ability to pay is a real constraint as is sources of funding.

city-centric in older metropolitan areas Direct patient services is experiencing rapid

5 Factors Going Forward Financial pressures - Rise in uncompensated care - Reductions in Medicare reimbursement - Aging Facilities and capital needs Increasing demand for care and access; e.g., chronic disease management Increasing shortage of physicians/surgeons relative to demand Mandated reduction in hours of Residents and Fellows- restricted to 80 hrs/week including call and moonlighting

ng Facilities and capital needs Increasing demand for care and access; e.g., chronic disease

6 US Bed Counts 1,000 # 900 Thousands

7 Workforce Challenges Shortage of primary care providers Maturing workforce On-going changes in skills and competency requirements Need to increase both productivity, quality, and access to care

8 Healthcare Workforce Caregivers Year Shortages Nurses ,000 Physicians: Primary ,000 Care Physicians: Surgery ,000 Physicians: Medical Specialty Physicians: Other Specialty Physicians: total before reform Physicians: reform impact Physicians: total with reform , , , , ,000 National Center for Health Statistics

Specialty Physicians: total before reform Physicians: reform impact Physicians: total with

9 National Center for Health Workforce Analysis Data Research Performance Measures Coordinate work with Grantees

10 Health Care Reform 2010 Affordable Care Act Legislation enacted will provide insurance coverage to health care for 32 million more Americans; the implications of this new demand on the nation s health care system are significant

for 32 million more Americans; the implications of this

11 IOM Healthcare Vision Quality care accessible to diverse populations Wellness promotion and disease prevention Improve health outcomes Compassionate care across the lifespan Maximizing provider practice levels

prevention Improve health outcomes Compassionate

12 Primary Care and prevention are central drivers of the health care system Collaboration among health care providers is and will continue to be imperative

13 Non-Physician Providers A licensed clinical medical professional who provides patient care under the supervision of and/or collaboration with a physician. Mid-levels include: - Nurse Practitioners (NP) - Physician Assistants (PA) - Certified Registered Nurse Anesthetists (CRNA) - Certified Nurse Midwives (CNM) - Clinical Nurse Specialists (CNS) Varying scopes of practices among states

Mid-levels include: - Nurse Practitioners (NP) - Physician Assistants (PA) - Certified

14 Current State of Non-Physician Providers Numbers of mid level providers have increased dramatically in the 1990s and 2000s. As of 2005, the number of NPs, PAs, CNSs, and CNMs practicing in the U.S., increased about 160 percent from 1992.* Professionals becoming more widely accepted by physicians, patients, and the general public as key members of the health care delivery team. *Health Policy Institute, Medical College of Wisconsin, Milwaukee, Wisconsin

* Professionals becoming more widely accepted by physicians, patients, and the general public as key members of

15 Nurse practitioners (NP) Over 135,000 practicing in US NPs : % prescribe medications and write an average of 19 prescriptions/day - Hold prescriptive privilege in all 50 states, including some controlled substances in all but 3-20% practice in rural settings; 66% primary care; 31% in at least one nonprimary care site (ED, inpatient, or specialty practice) American Academy of Nurse Practitioners (AANP) 2010

all 50 states, including some controlled substances in all but 3-20% practice in rural settings; 66%

16 Certified nurse midwives (CNM) Currently 11,320 in US Licensed and have prescriptive authority in every state CNMs provide high-quality care with : - positive outcomes - High-levels of patient satisfaction - Lower cost due to fewer unnecessary invasive and expensive technologic interventions American College of Nurse-Midwives (ACNM) 2010

High-levels of patient satisfaction - Lower cost due to fewer unnecessary invasive

17 Certified Registered Nurse Anesthetists (CRNA) More than 42,000 in US 111 educational programs in US CRNAs: - administer 32 million anesthetics in each year - administer anesthesia for all types of surgical cases, from the simplest to the most complex - Primary anesthesia professional in rural America American Association of Nurse Anesthetists (AANA) 2010

anesthesia for all types of surgical cases, from the simplest to the most complex -

18 Physician assistants (PA) 72,433 eligible to practice in US PAs : - Reimbursed at % of a physician - High patient satisfaction - Average compensation significantly below physician s - All states, the District of Columbia, the Commonwealth of the Northern Mariana Islands and Guam permit delegated prescribing by PAs, and nearly all states include controlled substances in that authority - PAs recommended or prescribed an estimated 332 million pharmaceutical products in % practice in hospital settings; 35% Grp physician practices; 9% solo physician practice; 8% Community/Rural Health Centers; 10% other American Academy of Physicians Assistants (AAPA) 2010

and nearly all states include controlled substances in that authority - PAs recommended or prescribed an estimated 332 million pharmaceutical products in 2008-38%

19 Clinical Nurse Specialist (CNS) 69,017 eligible to practice in US 14,643 are qualified to work as a NP and CNS Expert clinicians in a specialized area of nursing practice Specialty area based on population, disease, setting, type of care, or problem Practice in a wide variety of health care settings State laws and administrative rules issued by state licensing boards vary among states National Association of Clinical Nurse Specialists (NACNS) 2010

setting, type of care, or problem Practice in a wide variety of health care settings State laws and

20 Current Roles Acute Care Ambulatory Care Home Care Urgent Care Clinics Minute Clinics Physician Practices Hospital services; specialty surgical services Various roles across the continuum of care

21 Current and Future Challenges Variability in scope of practice Decreased reimbursement IOM recommendations Partnership and collaboration Team approach in meeting healthcare demands

22 Physician/Non Physician Provider Collaboration: Working as a Team

26 Panel Members Shannon Phillips, MD, MPH Gerri Lamb, PhD, RN Josanne K. Pagel, MPAS, PA-C Janet Fuchs, MSN, MBA, NEA- BC

27 Panel Questions The Evolving Role of the Mid-level Providers: Where are we headed? Is this a quality or cost-saving trend?

Randy Fink Frontier Nursing University December 5 th, 2012

Randy Fink Frontier Nursing University December 5 th, 2012 A Registered Nurse trained in one of four advanced practice roles at the graduate level (National Council of State Boards of Nursing, 2008) Certified