Physician organizations cheered on the American Academy of Family Physicians for issuing a report that not only advocated for the patient-centered medical home model of team-based care, but also for insisting that those teams be led by doctors. Nurses did not have the same reaction.
The report exposed a rift likely to deepen. Many see wider use of nurse practitioners as necessary amid a shortage of physicians in some areas, and the ranks of medical homes are growing under the encouragement of state and federal policymakers, providers and insurers who all see the model as having the potential to improve outcomes and lower costs by coordinating patient care across a fragmented system.
As the American Academy of Nurse Practitioners was quick to point out, none of the bodies that certify or recognize medical homes, such as the National Committee for Quality Assurance and the Joint Commission, require them to be physician-led.
The issue entered the political arena last month as a bill in the California Legislature that was supported by the California Academy of Family Physicians sought to legally define a patient-centered medical home as a practice that “facilitates a relationship between a patient and his or her personal physician and surgeon or other licensed primary-care provider in a physician-directed practice team to provide comprehensive and culturally competent primary and preventive care.”
Gov. Jerry Brown vetoed the bill. “While this concept is not new, it is still evolving,” Brown wrote in his Sept. 30 veto message. “For this reason, I think more work is needed before we codify the definition contained in this bill.”
At a news conference heralding the release of the AAFP report, titled Primary Care for the 21st Century, Dr. Roland Goertz, the AAFP's board chairman, said that allowing nurse practitioners to practice independently would create two classes of care: One led by physicians and another led by “less qualified” individuals. This point was echoed by John Crosby, executive director of the American Osteopathic Association.
“While there is an unarguable need for more primary-care providers in this country, this report underscores our belief that a team led by a fully licensed physician—D.O. or M.D.—is the best way to ensure that patients receive the highest level of care,” Crosby said in a news release that also included words of support from Dr. Jeremy Lazarus, president of the American Medical Association, and Dr. Robert Block, president of the American Academy of Pediatrics.
The AANP fired back with a statement calling the report “misdirected and out of step with today's environment.” This charge was repeated on Twitter by Christine Kirkman, a registered nurse from Syracuse, N.Y., who tweeted “Perhaps the report from the AAFP should be titled 'Primary Care for the 19th Century.' It is time to get with the times!' ”
Sean Lyon, a nurse practitioner at Life Long Care, a physician-less practice in New London, N.H., had a similar opinion. “I find the document to be comical to say the least,” he said in an interview. Lyon noted that the report includes a chapter titled “Our Primary Care System is Changing.” “The irony is that they're not changing with it,” said Lyon, who believes his practice—with 3,000 patients and four nurse practitioners—could be the first NP-led medical home to achieve the highest classification (Level 3) in the NCQA scoring system for the model.
The NCQA has recognized 4,772 sites as medical homes, the Accreditation Association for Ambulatory Health Care has accredited 122 and the Joint Commission has certified 26 organizations as primary-care medical homes. All three, however, said they do not keep track of how many are NP-led.
The AAFP report stressed that physicians undergo four years of medical school followed by at least another three years of clinical residency training, while nurse practitioners typically enter the workforce after finishing programs that run between 18 and 36 months.
The difference is significant, said Dr. LaDona Schmidt, who went to medical school after working as a nurse practitioner. “I've been there and done that,” she said. “When I was accepted to medical school, I thought it was going to be easy because I was so close to being a doctor already. But I didn't know what I didn't know, and I'm still learning, and I've been in practice for 18 years.”
Schmidt practices at Comcare in Salina, Kan., along with 21 other family physicians, six nurse practitioners and two physician assistants. “The difference in training is huge, and I don't want to seem anti-NP,” she said. “I would not survive without our NPs and PAs; I just don't think they should practice independently.”
Schmidt recalled a case in which a 2-year-old boy who had been diagnosed with stomach flu by a nurse practitioner at an urgent-care center. Schmidt said she noticed he also had yellow discoloration in his eyes. She examined him further and noticed he had an enlarged liver. Ultimately, he required a life-saving liver transplant, she said.
Lyon, however, offered an anecdote of his own. The nurse practitioner recalled treating a boy—described as “uninsured and living between two households”—who required treatment for his asthma even though he had been discharged from a hospital emergency department the day before after receiving asthma treatment. The problem, Lyon said, was that the boy was discharged without being given an asthma action plan.
“I'm not saying the emergency room doc screwed up,” Lyon said. Rather, the incident in his view exposed a broken link in the healthcare system that can be fixed with the medical home model and for less expense by an NP-led medical home such as his.
One obstacle for his practice, Lyon said, has been the expense of acquiring a health IT system without federal subsidies. Under the terms of the American Recovery and Reinvestment Act of 2009, the stimulus law that appropriated billions to help doctors and hospitals buy electronic health records, Lyon said, “We would need to be legally related to a physician who is officially supervising us” to qualify.