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Primary Care Delivery Changes as Nonphysician Clinicians Gain Independence

Jennifer Fisher Wilson
[+] Article, Author, and Disclosure Information

Potential Financial Conflicts of Interest: None disclosed.

Ann Intern Med. 2008;149(8):597-600. doi:10.7326/0003-4819-149-8-200810210-00025
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States across the United States have expanded health insurance coverage to more of their uninsured residents, resulting in at least 1 million more people having health insurance in 2007 than in 2006. These state-level health reforms should result in improved health care for a greater portion of the population. But the shortage of physicians, at least in some areas, has raised questions about whether the increased demand for care can be met. One study found that about 56 million U.S. residents do not have a regular source of health care because of physician shortages in their areas (1). Some patients now face long delays or many miles of travel to receive primary care.

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Nonphysician clinician discussion should include pharmacists
Posted on October 23, 2008
Erik D Maki
Drake University, College of Pharmacy and Health Sciences
Conflict of Interest: None Declared

In my opinion, pharmacists are the most underutilized member of the health care system. Pharmacy education has changed dramatically over the last 30 years, including the transition from the B.S. in pharmacy to the Doctor of Pharmacy degree and the availability and expansion of accredited post graduate residency training programs. Many pharmacists are capable and do provide high quality care throughout the health care system. Pharmacists have demonstrated their abilities to improve the outcomes of patients with many disease states, some examples of which include: Heart failure, diabetes and hypertension(1-3). Currently 45 states allow pharmacists to enter into collaborative drug therapy management (CDTM) agreements with physicians to increase patient access to quality health care(4). Pharmacists' ability to participate in the care of patients has not been limited by physician interest but because they are are not recognized as providers under Part B of the Medicare Program and thus cannot bill for services provided. In the VA system, pharmacists participation is not limited by the current reimbursement structure and they provide care in a number of diverse primary health care clinics(5).

As we try to improve patient access to quality care in the United States, pharmacists should be included in the conversation. Expanding the role of the pharmacist through Medicare provider status recognition should also be advocated.

1) Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist Care of Patients With Heart Failure: A Systematic Review of Randomized Trials. Arch Intern Med. 2008;168(7):687-694.

2) Wubben DP, Vivian EM. Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review. Pharmacotherapy. 2008 Apr; Vol. 28 (4), pp. 421-36.

3) Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, Carrell D, Tyll L, Larson EB, Thompson RS, JAMA: The Journal Of The American Medical Association [JAMA], ISSN: 1538-3598, 2008 Jun 25; Vol. 299 (24), pp. 2857-67

4) American Pharmacy Assocation. Collaborative Drug Therapy Management. Accessed 10/22/08. Available at: http://www.pharmacist.com/AM/Template.cfm? Section=State_Resources&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=16882

5) Cone SM, Brown MC, Stambaugh RL. Characteristics of ambulatory care clinics and pharmacists in Veterans Affairs medical centers: an update. Am J Health Syst Pharm. 2008 Apr 1; Vol. 65 (7), pp. 631-5.

Conflict of Interest:

Employed by Drake University College of Pharmacy and Health Sciences

Why there will always be a shortage of primary care providers
Posted on November 16, 2008
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

It should not surprise anyone that soon nurse practitioners (NPs) and physician assistants (PAs) will be sharing some primary care responsibilities with physicians. Clearly, there are not enough primary care physicians around.

However it is worthy of comment that increasingly, both PAs and NPs are specializing, with 70% of PAs in primary care specialties in 1974 versus 43% in 2004. Although the article mentions that, that like doctors, some PAs are driven towards specialization because the financial rewards are greater, I suspect there are other reasons as well.

Primary care requires a whole set of skills and personal characteristics that the academic medical community does not consider as important as the scientific ones. This mistaken approach, long held by the academic community has controlled and shaped the medical profession ever since the publication of the Flexner report almost a hundred years ago.

While "higher "“level academic credentialing" has done much to promote sound scientific medical practice, for which we are all grateful, it has also led to excessive deference to the science of medicine. This over-reliance on medical science has led to the devaluation of general practice and those qualities which define it.

General practitioners have as much a personal connection with their patients as a scientific one, sometimes the personal connection dominates. This distinctive connection is demanding. It cannot be taught. To a great degree it is not scientific and almost impossible to assess by academic standards, which explains in part why it registers so low on academic medicine's radar screen.

This personal connection which defines general practice is a unique factor with many attributes. It includes empathy, capability to coordinate care, finding the best specialist care, giving sound advice even when it conflicts with that of specialists, being available in times of physical and emotional crisis, navigating the confusing labyrinth of health care and many others.

General practice has never received either the academic recognition or the financial compensation it deserves because the aptitudes and abilities which define it have little scientific interest and thus are held in low esteem by the academic community.

Until our leadership acknowledges the century-long prejudice and neglect of primary care, this area of medicine will continue to decline and attract fewer practitioners.

And there will always be a shortage of primary care providers whether they are NPs, PAs, or MDs.

Conflict of Interest:

None declared

Nurse Practitioners May Practice Independently
Posted on January 30, 2009
Emily D. Patton
Mercy Iowa City
Conflict of Interest: None Declared

To the Editor:

The author has mistakenly categorized nurse practitioners with physician assistants as requiring physician collaboration in order to practice. In fact, with the exception of three or fewer states, nurse practitioners may practice as independent clinicians. The licensed practice of NPs is governed by the Nurse Practice Act of the state in which they practice; the licensed practice of PAs is governed by the state's Board of Medical Examiners and has always required physician oversight.

Conflict of Interest:

None declared

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