Physician assistants and nurse practitioners viewed as answer to doctor shortage

NORTHAMPTON — On any given day at Valley Medical Group’s Northampton Health Center, Christine Normandin sees up to 22 patients. She diagnoses and treats their ailments and advises them on improving their health. And sometimes, she corrects them when they call her “doctor.”

“I have to say, ‘I’m not a doctor, I’m a nurse practitioner,’” Normandin said in an interview at the health center on Main Street in Florence. Most patients are familiar with nurse practitioners and physician assistants, Normandin said, and they seem comfortable with the idea that they are the ones likely to be treating them.

Patients from western Massachusetts and across the country can expect to see more and more nurse practitioners and physician assistants in their exam rooms, according to experts in the health care field. This is because a trend toward using more of these professionals — sometimes called mid-level providers or advanced practitioners — is expected to continue, driven mainly by a shortage of primary care doctors.

It also saves money because they earn less than doctors, but administrators at two local hospitals said that is not the main driver of the change. The average base salary for both professions is about $90,000, less than half the $187,200 average salary of a physician, according to the Bureau of Labor Statistics.

“This is not a new phenomenon in Massachusetts,” said Dr. Joel A. Feinman, president and associate medical director at Valley Medical Group. “At Valley Medical Group, nurse practitioners and physician assistants have been in primary care since the mid-1980s, and we’ve hired more over time,” Feinman said. The ratio of doctors to nurse practitioners and physician assistants is now about 1-to-1 at Valley Medical Group facilities, he said.

Nurse practitioners and physician assistants are medical providers who are educated through master’s degree programs and hours of clinical experience — though they still spend less time and money on schooling than doctors. Required to practice under the supervision of a physician, they work with varying levels of autonomy in hospitals, medical centers or, in some states, even their own private practice. “They provide basic health care and handle complicated cases too. Some people prefer them because they can generally have a little more time with them than with doctors,” Feinman said. “They have a broad scope of practice. They can order tests and procedures and write prescriptions.”

Nationally, Feinman said, there has been a big need for primary care physicians, even before the Affordable Care Act created droves of newly insured patients. “The real problem is we’re not training enough primary care physicians,” he said. “More are training in specialties.” Doctors in specialties from cardiology or ophthalmology can earn more based on the way insurers and Medicare and Medicaid reimburse them, he said.

“I’d guess the trend will continue until they change the reimbursement system. Right now it really favors specialists over primary care physicians,” he said. “I think it’s a good trend. It’s improving access to primary care in a time when we need it.”

Stephanie Ahmed, a nurse practitioner and president of the Massachusetts Coalition of Nurse Practitioners, said that Massachusetts is not exempt from the primary care physician shortage, despite the 7,763 nurse practitioners working in the state.

“The farther away you get from Boston, the harder it is to get family care,” Ahmed said in a phone interview.

According to a 2013 Access to Care Study put out by the Massachusetts Medical Society, new patients in Franklin County had the longest wait to get a family practice appointment at 106 days. That’s followed by the three other counties in western Massachusetts: Berkshire County is second at 102 days, Hampden County is third at 58 days, and Hampshire County has the fourth longest wait in the state at 56 days. The state average was 39 days in 2013, the report said. According to the same study, around half of family medicine physicians in western Massachusetts were accepting new patients in 2013.

“That’s basic health care. People don’t expect to wait 102 days,” Ahmed said.

In the trenches

Normandin, of Florence, has been a nurse for 36 years and a nurse practitioner for 22. She has treated patients at urgent care centers on Cape Cod, students at Smith College Medical Services, and has worked at Valley Medical Group since 1993.

In addition to seeing patients, Normandin is practitioner team leader at the Northampton Health Center. She is responsible for scheduling, performance reviews, and other tasks to coordinate care among the center’s eight doctors, four nurse practitioners and three physician assistants.

The system at Valley Medical Group is called collaborative practice. Each team is made up of a physician, a nurse practitioner or physician assistant, a nurse, a medical assistant and a receptionist. “As a team, we’re really taking care of that patient,” she said. While a physician will schedule four patients per hour, Normandin said a nurse practitioner or physician assistant will see three each hour.

“We’re taking a little more time to look at the whole picture,” she said. “We have a little bit more time, and we have that in our heads, so we can let a person talk about the death of a spouse, or talk about how they felt when their cancer came back. A lot of what we do is counseling.”

Normandin said that varies among facilities. For instance, at urgent care centers, nurse practitioners may not have the benefit of a patient history to help them look at the whole picture of patient health. She has worked at some facilities where nurse practitioners and physician assistants saw the same number of patients per hour as a doctor, she added.

And while the two professions are sometimes grouped together under the name “mid-level providers,” Normandin said she does not like that term. “The schooling is different for nurse practitioners and physician assistants — nurse practitioners practice from a nursing model while physician assistants learn more of a medical model. But our practice is basically the same in this building,” she said.

The training programs for the two professions were formed in the mid-1960s, but their roots go back to the shortage of doctors during World War II, according to Normandin and John McGinnity, president of the American Academy of Physician Assistants.

“There was a shortage of professionals and a need especially for rural medicine,” McGinnity said. “That’s really the same issue we’re having right now, and that’s why we’re seeing more and more programs” training physician assistants. Among those programs is Bay Path College’s physician assistant studies graduate program, which graduated its first class in 2012.

The differences between physician assistants and nurse practitioners is based on the type of training they receive, according to their respective national organizations. While both professions require a bachelor and master’s degree before certification, physician assistants attend a program modeled on the medical school curriculum that doctors go through. Nurse practitioners go to nursing school, where their education focuses more on looking at “the whole picture” of a patient’s health, as Normandin put it. Both are required to complete hours of clinical experience before they can be certified.

They may have specialties, but both nurse practitioners and physician assistants train and re-train in general medicine. Seventy-five percent of nurse practitioners work in primary care, according to the American Association of Nurse Practitioners, compared to about one-third of physician assistants.

About 37.5 percent of physician assistants work in hospitals, while 38.1 percent work in a group practice or solo physician office, according to the American Academy of Physician Assistants. McGinnity said hiring physician assistants can mean savings for health care systems, but not just because of their lower salaries compared to doctors. “To me it’s about a team. If you utilize everyone to the top of their ability, you increase efficiency and cut costs,” he said.

Douglas Muehlberg, chief operating officer of Baystate Medical Practices, said compensation rates are not the biggest reason the Springfield-based provider hires physician assistants and nurse practitioners, or “advanced practitioners.”

“What’s much more important is enabling providers to make the most of their time with patients and make the greatest-possible contributions to their patients’ health,” Muehlberg said in an email. “In other words, allow doctors to spend time doing things that only doctors can do, and advanced practitioners to spend time doing things at which they’re most effective, too.”

Over the last five years, the number of nurse practitioners and physician assistants employed by Baystate Medical Practices has increased by 60 full-time-equivalent positions, or 40 percent, he said. “There are a total of 210 at Baystate Medical Practices including 20 in the primary care network,” he said. “In terms of ratios for all of Baystate Medical Practices it is approximately two nurse practitioners and physician assistants for every five doctors.”

Physician assistants and nurse practitioners are required to work under the supervision of a physician, but regulations that restrict their autonomy vary by state and even medical practice. Some medical centers may require doctors to directly supervise a physician assistant or nurse practitioner, while others may require them to collaborate only when required by law.

Some rules are arbitrary and outdated, said Stephanie Ahmed, a nurse practitioner and president of the Massachusetts Coalition of Nurse Practitioners.

“Nurse practitioners in Massachusetts can own their own business, but they have to pay a doctor to oversee their prescriptive practice. There is no data that having a doctor look at prescriptions after they’re written” has any positive outcome, Ahmed said. She said Massachusetts lags behind in terms of allowing nurse practitioners the freedom to practice and use their training. “We’re trained to take care of patients. We’re prepared to the full extent necessary,” she said.

McGinnity said there are many similar regulations that physician assistants face. “A physician assistant may take care of a patient for 20 years, but then, a physician assistant can’t do hospice,” he said, so a doctor would be needed. But as people recognize the value of physician assistants, McGinnity said, “barriers are dropping.” In 2014, 49 states and Washington, D.C., changed one or more regulations for physician assistants, he said.

Rebecca Everett can be reached at reverett@gazettenet.com.