facilitate their contributions, including revising state “scope-of-practice” laws and payment reform that emphasizes the team as the payment unit.

Steven J. Spear of the Massachusetts Institute of Technology suggests that large opportunities currently exist to advance quality, access, and cost simultaneously by focusing on care delivery. Despite significant disparities between the quality of providers, patients and payers cannot distinguish which providers provide the highest-quality care at affordable cost. By focusing on empowering patients and payers with this information, he explains, transparency has the ability to promote efficiency within the healthcare system.


Mary D. Naylor, Ph.D., R.N.

University of Pennsylvania School of Nursing

Over the last decade, there has been a growing awareness of the lags in healthcare quality in the United States. Today’s system is plagued by suboptimal, uneven, and error-prone care. While early reports published by the Institute of Medicine (IOM) (IOM, 2001; Kohn et al., 2000) placed a spotlight on healthcare quality, more recent reports (AHRQ, 2007, 2008; The Commonwealth Fund Commission on a High Performance Health System, 2008; Joint Commission, 2008) have generated new knowledge in this area and confirmed what we have suspected for years—that tremendous dysfunction, chaos, and underperformance exist in every setting of health care and for all patients.

These quality lags are particularly alarming when taking our nation’s healthcare investment into account. This year, the United States will spend more than $2.5 trillion on health care, an estimated 17 percent of the gross domestic product (GDP). By 2017, U.S. healthcare spending is expected to nearly double from 2007’s projected level, reaching $4.3 trillion and consuming 19.5 percent of the nation’s GDP (Anonymous, 2008). While U.S. spending surpasses that of other developed countries, outcomes lag for key indicators such as preterm births, infant mortality, and life expectancy.

To interrupt these trends, national leaders are exploring solutions that both improve outcomes and lower costs. This paper is based on the underlying assumption that “the needs and preferences of every patient should be met by the healthcare professional with the most appropriate skills and training to provide the necessary care” (American College of Physicians, 2009). It summarizes the evidence base that demonstrates cost savings and performance improvements by maximizing the existing healthcare workforce, including licensed independent practitioners and physician assistants (PAs). Four key questions have been addressed:

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