Practitioners marginalized
The Patient Centered Medical Home model has gained much ground as a proposed design for the delivery of successful primary care in the United States. The goal is better care through the coordination of services provided by a well-rounded team following a comprehensive patient-centered approach.
Reimbursement of service is based upon quality of care, not volume.
Currently, both physicians and nurse practitioners perform this type of care, but the American Academy of Family Physicians recently produced a statement regarding which professions it feels are qualified to run a PCMH. Despite the involvement by doctors and nurse practitioners, the AAFP declaration proposes that only physicians are qualified to perform in this role. They also say nurse practitioners lack the skills to lead in this type of care. They base their statement solely on the fact that family practice physicians have more education, and that polls indicate that, if given a choice, Americans will chose a physician over a nurse practitioner. Nowhere was there any documentation showing that care provided by a nurse practitioner was associated with lesser quality, decreased health outcomes, or increased cost.
To me, both physicians and nurse practitioners possess the training that qualifies them to do the job.
The shortage of primary care physicians is well-documented. According to a 2010 report from the American Association of Medical College, the United States will have a deficit of 45,000 primary care providers in the next 10 years. In just a few years, we will need several thousand more. Contributing to this shortage is the fact that fewer medical students are choosing the primary care pathway. This shortage is and will continue to disproportionately affect rural areas and the under-served. Therefore, the most logical solution is using advance-practice nursing to fill this need.
The foundations of nursing include patient-centered care of the whole person with a focus on preventive care – not just addressing the disease processes. In my opinion, the advanced-practice nurse is more than capable of coordinating and giving care, providing patient education, follow-up, and counseling. In fact, to me, the skills needed for the medical home model appear to more directly align with advanced nursing practice than with physician care. In general, physicians tend to provide care using a medical disease-oriented model. I am aware that medical school may provide more vigorous training to prepare a provider for care under the medical model, but this fact does not exclude nurse practitioners from the medical home role.
The real issue is: Do nurse practitioners have sufficient training to lead the medical home model? This question has already been answered, as nurse practitioners are currently successfully performing in these roles. An exhaustive review of the literature published in a 2009 Cochrane report titled “Substitution of Doctors by Nurses In Primary Care” supports this information. The report found that health care outcomes and cost efficiencies provided by nurse practitioners were as good as that of a physician. Therefore, I am baffled by the AAFP stance that under no circumstances should a nurse practitioner lead a medical home.
It is clear that nurse practitioners, adequately trained, are able to provide quality care and at a lesser cost. They are also able to fill a demand for care in a critical shortage area that is not likely to change anytime in the near future. It is surprising at a time of forecasted shortages (due to the failure of the medical education system to produce adequate numbers of providers to fill our country’s needs) that the AAFP would attempt to eliminate a source of proven health care providers for the very model of which nursing has been a proponent all along. This is a time for unification and problem solving, not division. The need is great and there is room for providers of both professions to effectively fill this dire need.