How To Help Your Health Care With A Health Care Program

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1 What is REFinE-PHC The Centre for Health Economics Research and Evaluation (CHERE) at the University of Technology, Sydney is the lead institution in a collaboration which has been awarded $2.5m in funding from the Australian Primary Health Care Institute (APHCRI) to establish a Centre of Research Excellence in the Finance and Economics of Primary Care (REFinE-PHC). Other partners are the University of New South Wales and the Australian National University. REFinE-PHC will focus on the economics and finance of primary care in Australia and build an evidence base to support primary care reform. Fact Sheets REFinE-PHC will produce a series of fact sheets as resources for primary healthcare providers, policy makers and other CREs. Author: Virginia Mumford and Marion Haas Nurse Practitioners and Physician Assistants: Adapting models of care to changing demographics SUMMARY In order to combat predicted shortages in health workers and to adapt to a changing patterns of health care in Australia a number of programs have been introduced or piloted. Some of these are aimed at retaining existing health workers through recognizing advanced training and skill attainment. Other programs are aimed at introducing new roles to both complement and substitute existing practices of care. This paper discusses two of these roles: Nurse Practitioners (NP) and Physician Assistants (PA). Both of these professions are part of accepted practice in a number of countries; Table 1 summarises a comparison with other English speaking OECD countries (United Kingdom, United States, Canada and New Zealand). These two roles are interesting in that they have many aspects in common in terms of practical skills and applications. However, they are fundamentally different in terms of academic underpinning. Nurse Practitioners (NPs) are experienced nurses with advanced degrees, who can set up an independent practice. Physician Assistants (PAs) are trained in a medical model of examination and diagnosis and work under supervision of a named medical supervisor. In essence this effectively provides an ongoing supply of permanent junior medical staff working with autonomy but under supervision. NPs are more established in Australia with funding through the Medical Benefits Scheme (MBS) and ability to prescribe under the Pharmaceutical Benefits Scheme (PBS), whereas although PAs have been the subject of several pilot studies, the legislation regarding funding and prescribing capability has not yet been enacted. For more information about REFinE-PHC, or for other fact sheets in this series, please see our website: 1

2 Nurse Practitioners and Physician Assistants: Adapting models of care to changing demographics Background PAs originated in the United States (US) during the 1960s in response to a medical shortage in health workers and a supply of army corpsmen who had received significant medical training. Despite initial opposition from the medical establishment, a three-year pilot program was set up comprising the elements of basic medical education. The main difference between the medical and PA programs is in terms of the length of training with PAs completing a three year program versus five years for entry level doctors. PAs undergo clinical placements in a number of clinical areas including: general practice; paediatrics; geriatrics; emergency medicine; mental health; surgery; women s health; and general medicine. These placements are for a shorter duration than is common with medical training but PAs also have ongoing requirements in terms is in terms of post-graduate study and need to undergo continuing education of 100 hours every two years, and pass a re-certification examination every 6 years. PAs can also specialize in a particular clinical area (such as surgery or general practice) and undergo additional vocational training in order to negotiate their level of autonomy with their supervising doctor. In 2010 there were 83,600 PAs working in the US according to a census taken by the American Academy of Physician Assistants(AAPA),[1] although the Agency for Healthcare Research and Quality (AHRQ) estimates a smaller number at 70,383 based on National Provider Identifier data[2]. The US Bureau of Labor Statistics[3] also indicated a median salary of USD86,410 with job growth prospects between of 30%, in excess of the average of 14%. This compares to a median annual pay for primary care doctors of USD $202,392, and $356,885 for specialists in 2010.[4] Nurse practitioners also originated in the US to address increased demand following the introduction of Medicare and Medicaid opened up access to medical care. The first education programs were established in 1965 [5], and although NPs were able to get direct access to federal funding under schemes to provide better access in rural areas, it was not until 1997 that NPs were able to obtain full provider status. The formation of the National Nurse Practitioner Coalition (now called the 2

3 American Association of Nurse Practitioners (AANP)) in 1992 created a strong lobbying platform for NPs and provided a professional focus with the publication of the Journal for Nurse Practitioners ( NPs work in a variety of fields relating to both hospital and community settings and have fairly comprehensive prescribing ability apart from controlled drugs. NPs may order, perform and interpret diagnostic tests, including blood tests and x-rays and are trained academically to a masters level with increasing discussion over the need for doctorate level study[6]. NPs are licensed by the states they practice in and there are significant differences across the states especially in terms of autonomy with different levels of collaboration and oversight by medical practitioners. [7] The US Bureau of Labor Statistics only gives the median salaries of registered nurses (USD 64,690 in 2010) and does not show a separate category for NPs. In 2010 there were 103,073 NPs practicing in the US with 52% working in primary care.[2] Country comparison Canada, the United Kingdom and the Netherlands have implemented similar PA programs based around a model of restricted medical education and ongoing supervision. Canada followed the US training model but with a focus on PAs providing care to remote and indigenous communities. The UK program piloted PAs in both primary and hospital based care in keeping with the AAPA survey which shows 31% of US based PAs being employed in primary care, 11% in emergency care and 26% in surgery related specialties.[1] Pilot studies in both New Zealand and Canada were for both primary and secondary care although in many of the international pilots there were legal and logistic problems around prescribing rights for PAs. For NPs the change has been more gradual with the NP role evolving out of increasing education and training opportunities. All countries in our comparison follow a similar model with separate registration and training requirements. 3

4 Physician Assistants in Australia Pilot programs to assess the suitability of introducing PAs into the Australian health care system were implemented in Queensland and South Australia in This was initiated by a concern about the supply of doctors, especially those willing to work in primary care, and in rural and remote areas, as well concerns over increasing medical costs[8]. At a rural health services conference, Forde and O Connor [9]suggested that PAs would increase time for doctors to spend with more complex cases, reduce professional isolation for rural and remote doctors especially internationally trained graduates, create a pathway for health related professionals looking for a change in direction, and provide a more culturally sensitive health service. Despite some problems in dealing with logistical and legislative issues, for example MBS prescribing rights, [10] the pilot programs were considered successful and several training courses were implemented[11]. However, the scheme currently appears to have stalled with the University of Queensland closing its Masters program to new entrants in 2012, before the first wave of students graduated, although the three year BSc course offered by James Cook University is currently in its second year. One reason for this is that the supply of doctors has increased with medical school intakes doubling from 1660 in 2000 to 2469 in In addition there has been a focus on increasing the supply of general practitioners (GPs) through doubling the general practice training places by 2014[12]. This has increased the pressure on training programs and internships and created a potential conflict between PAs and medical trainees, an issue highlighted by the Australian Medical Student s Association in a 2010 policy brief[13]. A position statement from the Australian College of Rural and Remote Medicine (ACRRM) is more supportive of PAs in rural and remote communities in order to extend the reach of existing services and suggests that clinical placements will need to be carefully managed to ensure both type of practitioners get sufficient clinical exposure in their training.[8] Nurse Practitioners in Australia Nurse practitioners have evolved from a number of advanced practice nursing groups and are more established with 843 in practice as of March 2013.[14] In addition the 2009/10 Federal budget allowed for nurse practitioners and midwives to provide certain MBS funded services and to 4

5 prescribe certain medications that are subsidized by the PBS scheme[15]. NP training in Australia follows the US model of a Masters level degree course and endorsement against competency standards developed by the Australian Nursing and Midwifery Council (ANMC). The role NPs can play in a complex care environment can be illustrated by looking at avoidable admissions. In Australia AIHW uses the definition of ambulatory care sensitive (ACS) admissions which includes: 1) those that can be prevented through immunisation; 2) acute conditions that can be easily treated in a primary care setting (for example through the use of antibiotics); and 3) selected chronic conditions that can be actively managed with treatment, education and lifestyle changes. In , 8.7% of all hospital admissions were attributed to ACS conditions with the main cause being diabetic complications (25.6% of all ACS admissions).[16] The over 75 age group was responsible for 22% of ACS admissions which is in keeping with international studies which showed that admissions in the older age group, especially for those suffering from dementia, could be reduced with prompt and effective treatment in a primary or community care setting. The Australian Institute of Health and Welfare (AIHW) have highlighted Residential Aged Care Facilities (RACF) as a potential area for PAs and NPs[17] with US research indicating that rates of potentially avoidable hospitalisations fell by 19 to 23 per year per 100 residents for RACFs with a full-time nurse practitioner[18]. Ouslander et al (2010) reported a 17% reduction in self-reported hospital admissions in 25 RACFs from the same 6-month period in the previous year following introduction of a NP led quality improvement program to detect and treat deterioration in residents of RACFs.[19] The program was estimated to produce Medicare savings of USD1, 250 per resident per year versus implementation costs of USD 77[19]. These results have resulted in an ACT aged care NP pilot program in 2008 and a federally funded AUD18.7m program in 2011 for NPs in residential and community-based care settings.[17] Implementing NP and PA programs Research on the effectiveness and efficiency of NPs and PAs mainly originates from the US where the absolute numbers of PAs and NPs are higher. Horrocks et al (2002) [20] reviewed 11 randomised controlled trials and 23 observational studies where NPs substituted for doctors as the first point of care for undifferentiated conditions presenting to either primary care or emergency departments. Patient satisfaction was generally higher with NPs, but no differences were found for prescriptions, 5

6 referrals or return consultations. The effect on costs was also not clear as the lower salaries for NPs were offset by longer consultation times and a higher number of diagnostic investigations. The authors note that an important concept in primary care is the early detection of serious illness but the studies were not designed to detect longer term health outcomes or equivalence of care. In addition the setting for most studies was NPs working within a medical team, and the outcomes were not tested for NPs working independently and autonomously. In the US, these concepts of autonomy and independence remain unresolved with a recent study [21] showing that 66% of primary care doctors surveyed agreed that they provided a higher-quality examination and consultation whereas 75% of NPs disagreed. In the US different states have very different requirements in terms of independence of practice for NPs. Three of the largest states in terms of NP numbers (California, Florida and New York with 27% of total NPs) have restrictions over NP independence and have implemented various forms of shared protocols for care.[7] Other states allow complete independence for NPs with no requirement for collaboration with medical colleagues. The study[21] also showed a similar divide in terms of doctors and NPs over receiving the same payments for similar services (4% for doctors versus 64% for NPs). Debate over the use of NP/PA type programs is likely to increase in order to combat the combined effects of an ageing population and the increased access resulting from the Affordable Care Act with approximately 20 million previously uninsured people looking for medical coverage by 2015[22]. The Association of American Medical Colleges [23] predicts a shortfall of 90,000 doctors by 2020 and has urged for more residency places address this shortage. However, in a pattern similar to that facing Australian health policy planners, the shortages are not just due to total numbers of medical providers but the distribution in under-served areas [24] both from a regional and specialty perspective (especially primary care). One other issue surrounding the use of NPs and PAs is in terms of consent, a 2005 US study [25] of 507 patients found that 79.5% expected to see a physician, and although 50% were willing to see a PA or NP for minor injuries, this fell to 15-35% for moderate to severe injuries. This issue of blurred professional images in healthcare is addressed by Slade et al [26] in a dermatology setting where they advocate all patients should be clearly told the name and title when meeting a provider for the first time, but this is further complicated by successful lobbying by the AANP in many US states for 6

7 the NP to use the title doctor in a clinical setting. [7] The US Institute of Medicine committee on the future of nursing has a stated goal that Nurses should be full partners, with Physicians and other health professionals, in redesigning Health Care in the United State. [31 Achieving this could be problematic with the current level of disconnect and confusion in the definition, roles and responsibilities of NPs and PAs. The Australian Medical Association (AMA) has raised concerns about the independent status of nurse practitioners and lobbied hard to ensure that MBS/PBS access was related to collaboration between nurse and medical practitioners[27]. The AMA also provided guidelines on collaboration and stated that giving NPs MBS/PBS access should not be viewed as a substitution exercise leading to fragmentation of care, but as a way to extend and improve the complete patient care model. [28] Table 1 on the following pages, summarises the current status of Pas and NPs in Australia, the UK, US, Canada and New Zealand. 7

8 Australia UK US Canada NZ Physician Assistants Nurse Practitioners Physician Assistants Nurse Practitioners Physician Assistants Nurse Practitioners Physician Assistants Nurse Practitioners Physician Assistants Nurse Practitioners Year started 2009 pilot 's late 1990's but in armed forces in Launched 2001 Current numbers 30 AU trained 765 as of Sep - 70 by (research roundup) Job description Conduct complete physicals, provide treatment & counsel patients. Order & interpret test results & recommend treatment of patients. Administer therapeutic procedures. Prescribe therapy or medication with physician approval. Provide physicians with assistance during surgery An NP is a registered nurse educated & authorised to function autonomously & collaboratively in an advanced & extended clinical role. The NP role includes assessment & management of clients using nursing knowledge & skills & may include the direct referral of patients to other health care professionals, prescribing 200 in 2012, 21% in GP practice, 20% ED a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills & knowledge base to deliver holistic care & treatment within the general medical &/or general practice team under defined levels of supervision. UK Dept of 3,196 in 2006 (2/3 in primary care) An NP offers care complementary to that offered by doctors & other health care professionals & augments the care that a team can deliver, but can also act as a primary care provider 83,600 in 2010 A PA is a medical professional who works as part of a team with a doctor. A PA is a graduate of an accredited PA educational program who is nationally certified & state-licensed to practice medicine with the supervision of a physician. PAs perform physical examinations, diagnose & treat illnesses, 180,233 in 2011 An NP is a nurse with a graduate degree in advanced practice nursing. This allows the NP to provide a broad range of health care services, including: Taking the patient's history, performing a physical exam, & ordering appropriate laboratory tests & procedures, diagnosing, treating, & managing ~400, 46% from the armed forces PAs (PA) are academically prepared & highly skilled health care professionals who provide a broad range of medical services. ~3000 Pilot program in 2010 (US trained) in elective surgery - Additional pilot for 4 PAs in primary care In most provinces in Canada, NPs are able to diagnose & manage many disorders & chronic diseases, prescribe medications, order diagnostics, & refer you to specialists if needed. They are able to do complete physicals, & medicals required for most third party companies, & see patients with chronic The PA is a clinical role that sits alongside both nursing and medicine, working under the supervision of a vocationally registered doctor who remains responsible for the care of patients and determines the PA scope of practice. A demonstration was carried out at Counties Manukau District Health 63 in 2009 NPs are expert nurses who work within a specific area of practice incorporating advanced knowledge & skills. They practise both independently & in collaboration with other health care professionals to promote health, prevent disease & to diagnose, assess & manage people s health needs. They provide a wide range of 8

9 or complicated medical procedures. payscale.com Training UQ programme closed in 2009 but James Cook has a 3 yr BSc programme Pre-requisites Australia UK US Canada NZ medications & Health: ordering Competence diagnostic & investigations. Curriculum The scope of Framework practice of the for the PA NP is (2012) determined by the context of practice. Accredited training (MSc level) Postgraduate Diploma (similar to MB ChB) with practical placements MSc level but with RPL in some courses order & interpret lab tests, perform procedures, assist in surgery, provide patient education & counseling & make rounds in hospitals & nursing homes. All 50 states & the District of Columbia allow PAs to practice & prescribe medications. >130 Masters level programmes acute & chronic diseases, providing prescriptions & coordinating referrals, promoting healthy activities in collaboration with the patient MSC debate of Doctoral level BSc & MSc through three universities diseases like diabetes, hypertension, heart failure, osteoarthritis, & mental health concerns. They work in acute or primary care settings & some are also able to perform minor surgical procedures. Accredited ARNP training programs - often at Master's level - plus internship Board, where two UStrained PAs were employed for one year to work within the acute surgical unit at Middlemore Hospital. The second phase of the PA demonstration commenced in 2013 with four demonstration sites in primary care and rural hospital settings. Confirmed sites are Gore Health Limited, Radius Health and Midlands Health Network Approved 3 yr (FTE) as an Approved RN Approved BSc Undergraduate degree (or 2 RN N/A 4 years N/A assessment & treatment interventions, including differential diagnoses, ordering, conducting & interpreting diagnostic & laboratory tests, & administering therapies for the management of potential or actual health needs. Approved Masters degree 9

10 undergraduate degree in biological sciences, health sciences or related clinical field, plus 2 yrs clinical experience Australia UK US Canada NZ advanced BSc yrs coursework) in Health practice nurse. Sciences Registration/Accreditation & CPD Australian Australian Society of PAs Nursing & (ASPA) Midwifery Council National Competency Standards for the NP (ANMC, 2005) Clinical work settings Planned for rural & primary care, & other underserved areas Initially acute care - but 2009/10 budget gave access to MBS & PBS UK Association of PAs - formal registration still being reviewed but PAs required to re-certify every 6 years plus ongoing 40 hours CPD a year Nursing & Midwifery Council depends on area on expertise but mainly primary care Certified by National Commission on Certification of PAs (NCCPA), an independent accrediting agency, plus 100 hours of CPD every two years & pass a recertification examination every six years. > 50 different specialties across primary & secondary care American Academy of NPs (AANP) & State nursing boards. NP specialties include family practice, women's health, pediatrics, geriatrics, adult health, neonatology, psych/mental PA Certification Council of Canada (PACCC) -minimum of 25 credits per year during five-year certification cycle. Canadian Association of PAs (CAPA) Mainly primary & rural acute care Canadian NPs exam 1) Community (community clinics, healthcare centres, doctors offices, patients homes). 2) long-term care (nursing PAs in the demonstration sites are UStrained. Demonstration PAs are working in urban and rural hospital settings and in primary care. experience in a specific area of practice NCNZ - NP competencies & criteria Primary & Emergency care 10

11 Australia UK US Canada NZ health, & acute homes). 3) care. hospitals (outpatient clinics, emergency rooms & other patient areas). 4) NP-led clinics Pay range (payscale.com) $64,094 - $191,024 Ability to prescribe Limited in pilot studies Autonomy Under supervision of a named Medical Officer $49,133 - $136,754 upper end due to use of US trained PAs in pilot programs Certain drugs in approved clinical areas Practice independently MBS & PBS access on condition of collaboration with medical practitioners B& 7 to 8a Not yet - awaiting legislation Under supervision of a named physician AUD58,278 (GBP38,852) mysalary.com USD86,410 (median 2010 BLS) USD44, Yes Yes Yes - but varies with States, especially for controlled drugs Practice independently Professional autonomy under supervision - not independent Practice independently CAD 43,308-70,533 Healthcaresalarycanada.com CAD43,308-70,534 Yes Yes Not in pilot Yes - but requires extra training Tasks delegated by Supervisor Practice independently N/A Designated primary & secondary supervisors, signed practice plan Practice independently 11

12 References 1. American Academy of Physician Assistants AAPA Physician Assistant Census. Alexandria, VA: AAPA, Agency for Healthcare Research and Quality. Primary care workforce: Facts and Stats 2: AHRQ, Bureau of Labor Statistics. U.S. Department of Labor, Occupational Outlook Handbook, Edition, Physician Assistant: BLS, Medical Group Management Association. Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. CO, USA: MGMA - ACMPE, U.S. Department of Health and Human Services: Health Resources and Services Administration. The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses, Dracup K, Bryan-Brown CW. Doctor of Nursing Practice MRI or Total Body Scan? American Journal of Critical Care 2005;14(4): Pearson. J. The Pearson Report: The annual state-by-state national overview of nurse practitioner legislation and health care issues. The American Journal of Health Practitioners 2009;13(2): Health Workforce Australia. The potential role of Physician Assistants in the Australian context Final Report. Adelaide: HWA, Forde A, O'Connor T. Augmenting the rural health workforce with physician assistants. In: Gregory G, ed. 10th National Rural Health Conference. Australia: National Rural Health Alliance, Ho. P, Maddern. GJ. Physician assistants: employing a new health provider in the South Australian health system. Med J Aust 2011; 194 (5): Kurti L, Rudland S, Wilkinson R, et al. Physician s assistants: a workforce solution for Australia? Australian Journal of Primary Health 2011;17(1): Health Workforce Australia. Australia's Health Workforce Series - Doctors in focus. Adelaide,

13 13. Association AMS. Policy Document: Physician Assistants and their impact on medical student training Australia NaMBo. Nurse and Midwife Registrant Data: March Melbourne: NMBA, Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 No. 29. Australia, Page A, Ambrose S, Glover J, et al. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions. Adelaide: PHIDU, University of Adelaide, Australian Institute of Health and Welfare. Dementia care in hospitals: costs and strategies.. Canberra: AIHW, Porell FW, Carter M. Discretionary Hospitalization of Nursing Home Residents With and Without Alzheimer s Disease: A Multilevel Analysis. Journal of Aging and Health 2005;17(2): doi: / [published Online First: Epub Date]. 19. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society 2011;59(4): doi: /j x[published Online First: Epub Date]. 20. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 2002;324(7341): Donelan K, DesRoches CM, Dittus RS, et al. Perspectives of Physicians and Nurse Practitioners on Primary Care Practice. New England Journal of Medicine 2013;368(20): doi: doi: /nejmsa [published Online First: Epub Date]. 22. Office CB. Effects on Health Insurance and the Federal Budget for the Insurance Coverage Provisions in the Affordable Care Act May 2013 Baseline, Association of American Medical Colleges. AAMC Physician Workforce Policy Recommendations. Washington, DC: AAMC, Igelhart. JK. Expanding the role of advanced Nurse Practitioners - Risks and Rewards. New England Journal of Medicine 2013;368(20):

14 25. Larkin GL, Hooker R. Patient Willingnesss to be seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the presumption of assent have an empirical basis? The American Journal of Bioethics 20101;10(8): Slade. K, Lazenby. M, Grant-Kels. JM. Ethics of utilizing nurse practitioners and physician's assistants in the dermatology setting. Clinics in Dermatology 2012;30: Australian Medical Association. Position Statement: Independent Nurse Practitioners, Australian Medical Association. Collaborative Arrangements: What you need to know. Canberra: AMA,