Doctor Demand and Nurse Necessity: Shifting Roles in Healthcare

Liam Gallagher joined the Oxeon team this past summer after graduating from Williams College where he majored in Chemistry and English. Even having completed all the requirements necessary for medical school, he realized that he knew much too little about the industry of medicine. His work as an Associate across a number of Oxeon projects has afforded him an exceptional window into the evolving intersection of business and healthcare, as well as insight into the transformation of the medical profession. “I worked at Epic for a couple years after college, and now I’m in Nursing school at Columbia.”

I breathed a quiet sigh of relief. I’m new to dating, at least to what it looks like in New York City. On top of that, small talk is not a strength. So, when my blind date told me she was in healthcare, I was immensely relieved — talking to strangers about healthcare is my job after all!

But, not so fast.

“Oh awesome, I’m on my way to medical school!” I volunteered in response. Two raised eyebrows (not the good kind) let me know that I’d made a big mistake. It took the whole date and a couple of rounds to convince her that I was not, in fact, a jerk. This was my personal introduction to the often adversarial nature of the nurse-doctor dynamic.

I don’t mean to generalize this anecdote across all of healthcare. I’ve witnessed teams of doctors and nurses work beautifully together in the OR. But, as healthcare undergoes tumultuous, industry-wide reform, the reverberations are being felt at all levels. The driving question behind these changes: how can we keep people healthier, more efficiently? A corollary to that question is: who? – that is, who can keep people healthier, more efficiently? Is it doctors, public health officials, nurses, acupuncturists?

The reality is that what each of these roles means is changing, particularly for nurse practitioners (NPs) and physician assistants (PAs), or collectively non-physician providers (NPPs). One driving factor in these role shifts is a shortage of physicians; the AAMC predicts that we will be in the red by 130,000 MDs in about 10 years[i]. The shortage will be especially pronounced in primary care. Important, but a tad sensational, the AAMC’s prediction takes a very straightforward tack on the supply and demand trends. What it doesn’t do is account for the possibility that some of the big changes might profoundly impact the doctor-demand trend, specifically that the roles of non-physician providers will evolve to answer the unmet demand.

Healthcare is expensive, in part, because it is expensive to make a doctor. As a product, medical labor is tremendously costly to produce, and the way that the US goes about it isn’t terribly efficient either (this is the subject of a whole other article, or several). The educational path to becoming an NP takes about half the time and a twelfth of the cost as a doctor’s[ii].  Resistance to expanding the scope of NP roles, voiced primarily by physicians, warns of creating a two-class care system. These concerns seem valid in light of the differences in length of education and training. After all, who on his sickbed wouldn’t want his healthcare provider to be very, if over-, qualified? However, studies that have explored this question in the clinical data have found little evidence to back up this concern.

One such review that analyzed data from 37 articles published between 1990 and 2009 found that key metrics, including quality, safety, and effectiveness, were comparable for care delivered by NPs and MDs[iii]. There’s some evidence that patient satisfaction scores are actually higher for NPs, and we needn’t be too puzzled why. It’s not news that fiscal and organizational burdens placed on physicians are greatly limiting the amount of time they are able to spend with their patients. This lack of time is particularly harmful in the treatment of chronic and behavior-linked conditions, a particular area of focus in reducing healthcare costs. None of this is to suggest that NPs should or will replace doctors. In fact, one study found that outcomes were significantly higher for physician treatment in cases with high clinical complexity. If anything, the evidence indicates that we need to be more scientific in our decisions around who is best to provide care from both a clinical quality and cost perspective.

The place where NPs are often just as effective as MDs is primary care, precisely the field in which the doctor shortage will be and already is most pronounced. So, it’s good news that the vast majority of NPs practice as PCPs, roughly 80% of the 155,000 as of 2013[iv]. As healthcare has begun to focus and shift resources to primary care and preventative medicine, there has been enormous growth in a closely related field, urgent care. GoHealth, a rapidly growing urgent care company and new Oxeon client, is working to transform urgent care from a low cost alternative in a FFS world to a fully integrated part of our healthcare system. In doing so, they are leveraging non-physician providers to deliver the highest quality care while providing a phenomenal patient experience, and at a responsible cost.

One of the primary places where healthcare cost pressures are mounting is on the patient. The portion of the population enrolled in high deductible health plans (HDHPs) has steadily increased from less than a fifth to roughly a third in the last five years[v]. These plans encourage the patient herself to be cost-conscious in deciding where to seek care. The prevalence of HDHPs is even higher among younger, relatively healthy populations, who tend to utilize the healthcare system more episodically. The college student who sprains his ankle playing flag football or young professional with a mild skin infection is no longer likely to drive to the nearest emergency room. Beyond the endless wait times, it costs two to fives times more to treat such conditions in the ER than it does in an urgent care clinic. And, with a HDHP, those increased costs fall largely on the patient.

Over a quarter of all ER visits could be handled equally well in the urgent care setting, accounting for $4.4 billion in wasteful spending[vi]. Additionally, the kind of urgent conditions that do not require the ER tend to be those where non-physician providers can treat as well as MDs.

As with nearly all current transitions in healthcare, there is a utilitarian dilemma underlying the shift from the ER to the urgent care clinic: i.e. the rare instance when someone who needs the ER goes to a UCC and the clinical outcome is worse for it. There are a couple ways in which GoHealth’s model minimizes the likelihood of this scenario. The first is that, unlike many retail clinics, GoHealth clinics will have at least one board-certified physician, who will be able to identify such cases and take appropriate action. Secondly, the core of GoHealth’s model is integration with their health system partner, integration that will optimize referral streams and transitions from the urgent care clinic to more acute settings as well as longer term primary care providers. Beyond that, many GoHealth clinics will be positioned directly next-door to the overcrowded ERs of health system partners; essentially, this will provide a cost-saving layer of triage without adding any clinical risk.

‘Mid-level providers’ and ‘physician extenders’ are common terms that refer to nurse practitioners and physician assistants. They are becoming increasingly ill-suited for that task as NPs and PAs play more integral and more independent roles in healthcare. As our system becomes more sustainable and cost-conscious, perhaps the most important questions is “who?” Alignment, it seems, is the name of the game. There’s evidence that multidisciplinary teams – comprised of doctors, nurses, NPs, social workers – achieve the best clinical outcomes, especially for the highest acuity patients[vii]. So, ultimately, this question of ‘who’ really needn’t amplify antagonism in nurse-NPP-doctor relationships; instead, the right answer just might make it as much a thing of the past as white nursing caps.

Now, I’m just hoping that this team attitude can go beyond the clinical and help me out on our second date!


 

[i] Physician Shortages to Worsen Without Increases in Residency Training, American Medical Association, 2008

[ii] Education and Training: Family Physicians and Nurse Practitioners, American Academy of Family Physicians, 2010

[iii] J. Stanik-Hutt et al., The Quality and Effectiveness of Care Provided by Nurse Practitioners, Journal for Nurse Practitioners. 2013; 9(8):492-500

[iv] NP Facts, American Association of Nurse Practitioners, 2014

[v] Center for Disease Control and Medical Choice Network

[vi] Ibid.

[vii] M. Pinninti, Clinical Outcomes of Multidisciplinary Team Management in Patients Supported with Left Ventricular Assist Devices, The Journal of Heart and Lung Transplantation , Volume 33 , Issue 4 , S220