2. Nurse Practitioners and Physician Assistants as Primary Care Providers in Institutional Settings Written by Peter D. Jacobson, Louise E. Parker, and Ian D.Coulter (published in Inquiry, Winter 1998/99) Summary of the article presented by Shammima Jesmin

3. Background The authors realized that because of two reasons the health care administrator and policy makers are interested to reexamine the role of various health professional groups like nurse practitioners (NPs) and physician assistants (PAs). Those are: (i) a continually increasing demands for access to primary care services ; and (ii) the cost of providing such care. Despite realization of integrating Health professionals like NPs and PAs in healthcare delivery system in greater scale to expand the spectrum of access to primary care, there has been little empirical research documenting their actual primary care practice within the health care systems. This paper was based on the study through which the authors have tried to explore the role of these two professional groups, scope of their primary care practices and various factors influencing such practices in different health institutional settings under managed care system.

4. Previous research :Focused four interrelated issues. 1) Quality of Care: Found collaborating working environment between Physicians, NPs and PAs, even though much of those research suffers from several methodological flaws. 2) Substitutability: The quality of care research indicated that NPs and PAs can safely execute somewhere from 50% to 90% of all tasks generally performed in primary care practices. 3) Complementarity: NPs and PAs can provide some services such as prevention, education, and counseling, that complement traditional curative medical practice. Substitutability and Complementarity are needed to be re- examined in the face of changing health care delivery system. 4) Costs: The training costs for NPs and PAs are lower than for physicians. But there exist vast scope to assess health care costs by considering the amount of time spent with patients, the types and number of tests ordered by different providers, salary costs, and any cost savings from the NPs and PAs focus on prevention.

5. Objectives: i) Filling the gaps in the previous studies such as NPs and PAs function within the institutions and the nature of the working relationships between NPs, PAs, and physicians. ii) Generating the hypotheses for future research. The following research questions were addressed. What are the Nurse Practitioners (NAs) and Physician Assistants (PAs) scope of practice (range of health care tasks) and autonomy ( refers to NPs’ and PAs’ ability to determine independently the range of tasks) across different institutional practice setting? Who determines which tasks are to be performed? How are NPs and PAs integrated into the practices studied? What is the organizational context in which they function, including working relations with physicians?

6. Methodological Approach This study was carried out in late 1993 and early 1994 at nine Health Maintenance Organization(HMO) and Multi-specialty Clinics (MSCs) in urban and rural settings. On the basis of following three assumptions, purposive sampling methods instead of probability sampling has been used : 1) Practice of health care has become increasingly dominated by managed care organizations and integrated system, so private practices, community based centers and hospitals not the part of an HMOs or MSCs has been excluded. 2) Organizations that have had experience, over a number of years with NPs and PAs in primary care practices were selected. 3) To make the sample geographically diverse, states with varying legislative stringency regarding NP and PA practice were included for sampling purpose. Respondents were interviewed using semi-structured interview guide which was pre-tested for necessary modifications. Among the respondent were, Physicians, NPs, PAs, and Administrators

8. Results/Findings 1. Scope of care along with care coordination, prescription authority, test ordering practices, and referral authority. Scope of care: Two types of responses. a) Range of services: For most respondents the tasks grouped into the following categories: diagnosis(e.g physical exam. and test ordering); medical treatment(e.g. monitoring diabetes and hypertension), writing prescriptions; and providing monitor surgical treatment. b) Philosophy and breadth of care: NPs and PAs concentrated on wellness and prevention issues, not just medical symptoms. Many of them added that they take more time with patients than physicians. Care coordination: Coordination of care by NPs and PAs appeared to be less routine or expected in MSCs than in HMOs.

9. Results/Findings Continued Prescription Authority: It was found associated with organizational type but not with management style, greater prescription authority in HMOs and less in MSCs. Test ordering authority: For the most part test ordering authority was similar to physicians. 2. Cost difference between Physicians, and NPs and PAs: Respondents reported not too many differences in test ordering, referral patterns or prescription behavior between physicians, and NPs and PAs. 3.Limits to NPs’ and PAs’ scope of practice a) Elderly or more complicated patients are not usually treated by NPs and Pas they are referred to physicians. b) NPs and PAs lacks of authority to admit patients to hospital inpatient care. c) NPs and PAs are not held responsible for the patients same way as physicians.

10. Results/Findings Continued 4. Management style and its relation to organization type and scope of practices for NPs and PAs: It was found that the larger the managed care population the more likely the institution was to use team (NPs and PAs were assigned to teams that included physicians, NPs and PAs ) or panel management (each provider was assigned his or her own set of primary care patients- the NPs and PAs are responsible for the patients primary care needs including when to refer to a physician or to a specialist), the greater the NPs and PAs autonomy, and the broader their scope of practice as in HMOs than at institution favoring traditional management (NPs and PAs were assigned to a supervising physician or small group of physicians). 5. Professional autonomy: Look at the following Table.

12. Future Research Directions Questions are yet to be answered through more definitive research. What mix of providers can supply the most appropriate and cost-effective primary care? What are the barriers to increased use of NPs and PAs? What is the optimal management style for integrating NPs and PAs as primary care providers? What type of training should NPs and PAs receive to become primary care providers? Another set of questions involves the relative labor costs of using NPs and PAs as primary care providers.

13. Study limitations and recommendations According to authors, due to financial constraints and purpose of studies, a large sample could not be selected using probability sampling, the sample was not truly representative to generalize the findings of the study. This type of study could be done with truly representative sample from NPs and PAs from all levels and health care delivery systems to generalize the findings. The role of NPs and PAs as primary care physicians and scope of the practice can be examined through similar study from consumer perspective.

14. Conclusion The image of the health care service providers paraphrased by the authors “ NPs, and PAs, and physicians have opened different doors to the same room.” Despite varying scope of practices by NPs and PAs as primary care providers in different health management style and structure in managed health care system, their role to provide such care demands reassessment to integrate them into the system in large scale to meet the increasing demand of primary care needs by people.