Disincentive to becoming a doctor

Nurse practitioners and physician assistants – collectively known as advanced practice providers (APPs) – are valuable members of the healthcare team. However, they are not interchangeable with physicians. New legislation co-sponsored by 26th District Sen. Emily Randall, Washington State Senate Bill 5704, would mandate state-regulated commercial insurance carriers reimburse nurse practitioners and physicians equally, known as pay parity. In Washington State, most insurers, including Medicare and Medicaid, already reimburse equally. However, private health plans, like Premera and Regence, have reduced nurse practitioner reimbursement to 85% of the physician rate under certain circumstances, such as when family nurse practitioners work in emergency rooms or specialty clinics, in a scope for which they are not trained. This bill would remove that flexibility for private health plans.

Higher reimbursement for physicians incentivizes the future physician workforce. It acknowledges the difference between four years of medical school, 3-7 years of residency, and 12,000-16,000 direct patient care training hours of physicians compared with nurse practitioners, who complete 2-3 years of additional education, no residency, and only 500-1000 hours of direct patient care. In addition, those extra years of education are costly; medical students carry on average $200,000-$300,000 in educational debt by graduation. The question is rather simple: If one can earn the same income with 6-8 fewer years of education and far less debt, would anyone still want to become a physician? Not likely.

The physician workforce has been in steady decline in Washington State for the past five years. Policymakers who believe APPs and physicians are interchangeable promote the idea that APPs are a viable solution to the physician shortage. After writing a book on the subject of APPs in healthcare, "Patients at Risk: The rise of the nurse practitioner and physician assistant in healthcare," I am one of two national experts on the training, education, and cost discrepancies between these professions. I have read nearly every study published on this topic over the last five decades. The science is clear and definitive. Research demonstrates that when directly supervised by physicians, APPs provide high quality and safe care for patients. Unfortunately, no studies have scientifically evaluated care provided by APPs working independently. That is, until recently at the Hattiesburg Clinic.

The physician shortage is a national problem. Due to the dearth of primary care physicians in Mississippi, the Hattiesburg Clinic – a top accountable care organization – employed APPs as independent primary care practitioners, working side by side with physicians. Clinic leadership predicted independent APPs would provide care of similar quality and cost compared to that of physicians. And they were tremendously disappointed with the results. After evaluating 300 physicians, 150 APPs, 30,000 patients and 200,000 survey responses, researchers found that physicians provided the highest quality care at the lowest cost. In 9 out of 10 quality measures, physicians outperformed APPs. There were double-digit differences in some categories, such as influenza vaccination rates. Patients whose primary care was led by a nurse practitioner or physician assistant were referred to the emergency room nearly 2% more frequently and to specialists 8% more often.

The differences in healthcare costs were nothing short of astounding. After adjustment for complexity, patients cared for by APPs cost $119 more per member per month than those managed by physicians. Extrapolating this to 20,000 patients, means "the same care" costs $28.5 million more when provided by APPs. Study authors ultimately determined that while nurse practitioners and physician assistants provide care of high quality, the increased cost associated with independent care meant they should not manage patients without physician oversight.

Finally, if you are not convinced that SB 5704 is bad for Washingtonians, you should know that pay parity was heavily touted by President Trump, in the misguided attempt to privatize Medicare. Of course, pay parity rewards corporations, not frontline healthcare workers. Because large corporations can bill for care as if a physician treated you, yet pay nurse practitioners and physician assistants less, thereby generating substantially higher profits.

Nurse practitioners and physician assistants are an invaluable part of the healthcare system. They extend the capacity of physicians to treat patients. I work with a pediatric nurse practitioner who had extensive pediatric nursing experience prior to obtaining her advanced nursing degree and works within the scope for which she was educated and trained. While I value my nurse practitioner and physician assistant colleagues tremendously, especially throughout this pandemic, Washington State needs healthcare solutions that cost taxpayers less not more. The pay parity bill is not the solution for the physician shortage. It disincentivizes the future physician workforce, worsens the physician shortage, and increases healthcare costs significantly, the burden for which will be borne by future generations.

Dr. Niran Al-Agba is a pediatrician in Silverdale and writes a regular column for the Kitsap Sun. Contact her at [email protected].

Niran Al-Agba

Columnist