The story is familiar by now: The adoption of hotly debated legislation dramatically increases healthcare access for millions of Americans and the nation’s healthcare workforce is challenged in accommodating the surge, especially in rural areas.
But this wasn’t the Affordable Care Act. The year was 1965 and the legislation in question was the Social Security Amendments which created Medicare and Medicaid. As doctors braced for an influx of patients, national headlines asked if there was a “Crisis ahead in medical care?”
The healthcare sector found a potential solution to a looming workforce shortage in the form of two newly minted types of health care providers: nurse practitioners and physician assistants.
Fast forward to today and NPs and PAs, as they are now known, have become integral parts of the United States’ healthcare system. As the country faces another physician shortage, NPs and PAs are once again being identified as a means for expanding access to care.
The Beginnings
Eugene A. Stead Jr. M.D. is credited with coining the term “physician assistant” when he established the first PA program in the United States at Duke University. Stead envisioned the new category of healthcare professional as an answer to what he characterized as “a need for males to be committed to the health field to fill a gap between the physician and the nurse.”
The Duke program initially targeted former military medics or medical corpsmen, on the assumption that that they would come to the program with a basic medical background. Three of the four former Navy corpsman who first entered the two-year program in 1965 graduated in 1967. (And the gender exclusivity was short-lived, with the first woman completing the program in 1970.)
As the PA program was taking shape at Duke, Loretta Ford, EdD, PNP, FAAN, and Henry Silver, M.D. of the University of Colorado were pursuing another avenue for expanding the healthcare workforce. While Stead focused on the furthering the education of male medics, Ford and Silver recognized the potential in expanding the scope of education for the traditionally female nursing profession. Their nurse practitioner program—the first in the nation–began as a certificate program in 1965, with an initial focus on family health and expanding access to pediatric care in rural America.
Today’s NPs and PAs
Today there are over 290 PA programs and approximately 400 NP programs in the United States. While the graduates of these master’s level programs play important roles across multiple specialties, they play essential roles in the delivery of primary care. Of the approximately 132,940 physician assistants and 234,690 NPs in practice in the United States today, the vast majority are employed in physician offices, general medical hospitals, or outpatient care centers.
Both nurse practitioners and physician assistants are categorized as physician extenders under the Code of Federal Regulations (CFR). And, in a nod to the visions of Snead, Ford, and Silver the CFR also specifies that, to qualify as a rural health clinic, a clinic’s staff must “include one or more physician’s assistants or nurse practitioners.”
Per CMS, a physician assistant must be a graduate of a program accredited by the Accreditation Review Commission on Education for the Physician Assistant or have passed National Commission on Certification of Physician Assistants and be licensed by state in which they practice. Nurse Practitioners must be certified by one of seven recognized certifying bodies, registered as a professional nurse authorized by the state in which they practice, or have been grandfathered in under state law before 2020.
What’s in a name
Over the years, physician assistants and nurse practitioners have been called and categorized by many names, including advanced clinicians, physician extenders, non-physician providers, and mid-levels.
The AANP actively rejects the term physician extender, arguing instead for the use of such terms “primary care providers, health care providers, health care professionals, advanced practice providers, clinicians and/or prescribers.”
Following a vote by its House of Delegates in May 2021, American Association of Physician Assistants (AAPA) legally changed its name to the American Academy of Physician Associates, Inc. Although the organization counsels its members against employing the term “associate” in professional settings lest they run afoul of credentialling or licensing authorities, AAPA has committed to the long-term process of changing the physician assistant designation at both state and federal levels in order to “directly addresses the common misperception that PAs merely ‘assist’ physicians.”
Both the American Medical Association (AMA) and the American Osteopathic Association (AOA) issued statements in opposition to the proposed name change. AOA said that the “title change could easily create confusion for patients and put their safety at risk,” while the AMA characterized it as part of a larger attempt on the part of PAs “to advance their pursuit toward independent practice.”
Scope of practice
Scope of practice (SOP) laws for NPs and PAs vary by state. Currently, twenty-three states and the District of Columbia allow NPs to practice and prescribe medicine without physician supervision. Sixteen states specify that NPs can treat and diagnose patients, but require physician supervision for prescriptions, while 11 states specify that NPs must have physician supervision for diagnosis, treatment, and prescriptions.
Nearly all states require that PAs work under a supervisory agreement with a licensed physician and most set limits on the number of PAs any one physician can supervise. However, New Mexico, a predominantly rural state replete with Primary Care Health Professional Shortage Areas permits PAs with more than three years of clinical experience to work in primary care in “collaboration” with a licensed physician in an arrangement in which both parties “contribute to the health care and medical treatment of patients.”
CMS specifically allows for NPs and PAs to sign orders for Durable Medical Equipment Prosthetics, Orthotics Supplies (DMEPOS) provided to Medicare beneficiaries when they are authorized to do so in the state in which the order is made.
SOP Expansion
In order to expand access to care, most states waived supervisory restrictions on NPs and PAs in response to the pandemic. As state waivers expire and HHS prepares to end the Public Health Emergency, NPs, PAs, and physicians alike are wondering what exceptions, if any, will be extended.
The AMA contends that NP programs—the equivalent of two to three years or graduate education with 500-720 hours of clinical experience—and PA programs, which are generally completed in two-and-a-half years, with 2,000 of patient care hours do not adequately prepare their graduates for independent practice. Accordingly, the organization continues to call for “physician-led” care.
A 2017 comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers found no statistically significant differences in patient outcomes. And studies suggest that patients seen by NPs and PAs are more likely to receive health education and vaccinations than those seen by physicians.
Expanding the scope of practice for NPs and PAs in the large term will not be as quickly accomplished as waivers. As states address the question of where these providers fit in the larger healthcare system and how they can best be employed in expanding access to care, there will be lobbying efforts from both sides.