10
NONPHYSICIAN PRACTITIONERS

Early in the study the committee hypothesized that VA physician requirements—at present, but especially in the future—may be influenced by the availability of certain nonphysician practitioners (NPPs).

Included among these NPPs would be physician assistants (PAs), nurse practitioners (NPs), and other categories of providers, each of whom performs selected diagnostic and therapeutic patient care services under the supervision of a physician. In general, NPPs would affect physician requirements if (1) they can substitute directly for physicians in selected tasks or (2) work jointly with physicians in ways that boost net productivity.

The committee's interest in these providers was spurred by two considerations.

First, over the past 25 years or so, a substantial body of research has developed indicating that such NPPs can substitute for, or otherwise augment, the productivity of physicians in a range of private-and public-sector patient care settings (see, e.g., Becker et al., 1982; Cromwell and Rosenbach, 1990; Mendenhall et al., 1980; Office of Technology Assessment, 1986; and Spisso et al., 1990). Studies have concluded that in a variety of physician-supervised functions—ranging from physical evaluations to wound debridement to patient education to routine incisions—NPPs have rendered good-quality care efficiently and with high patient satisfaction. Many of these analyses reported the successful use of PAs and NPs in ambulatory and long-term care.

Second, the changing demographic structure of the VA patient population implies that an increasing proportion of patients will be over age 65, chronically ill, and will require care that may be appropriately delivered in ambulatory care or long-term care patient care areas (PCAs).

A natural question is whether an expanded use of NPPs, especially in primary care settings, can significantly increase physician productivity without compromising the quality of care.



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Physician Staffing for the VA: Volume I 10 NONPHYSICIAN PRACTITIONERS Early in the study the committee hypothesized that VA physician requirements—at present, but especially in the future—may be influenced by the availability of certain nonphysician practitioners (NPPs). Included among these NPPs would be physician assistants (PAs), nurse practitioners (NPs), and other categories of providers, each of whom performs selected diagnostic and therapeutic patient care services under the supervision of a physician. In general, NPPs would affect physician requirements if (1) they can substitute directly for physicians in selected tasks or (2) work jointly with physicians in ways that boost net productivity. The committee's interest in these providers was spurred by two considerations. First, over the past 25 years or so, a substantial body of research has developed indicating that such NPPs can substitute for, or otherwise augment, the productivity of physicians in a range of private-and public-sector patient care settings (see, e.g., Becker et al., 1982; Cromwell and Rosenbach, 1990; Mendenhall et al., 1980; Office of Technology Assessment, 1986; and Spisso et al., 1990). Studies have concluded that in a variety of physician-supervised functions—ranging from physical evaluations to wound debridement to patient education to routine incisions—NPPs have rendered good-quality care efficiently and with high patient satisfaction. Many of these analyses reported the successful use of PAs and NPs in ambulatory and long-term care. Second, the changing demographic structure of the VA patient population implies that an increasing proportion of patients will be over age 65, chronically ill, and will require care that may be appropriately delivered in ambulatory care or long-term care patient care areas (PCAs). A natural question is whether an expanded use of NPPs, especially in primary care settings, can significantly increase physician productivity without compromising the quality of care.

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Physician Staffing for the VA: Volume I To advise on how these and related issues might be investigated systematically, the committee established a nonphysician practitioners panel. In the course of the study, this panel examined the issues in some depth, conducting literature reviews and three field surveys that involved NPPs, their supervisors, and chiefs of staff in a national sample of VA medical centers (VAMCs). The panel's analyses, deliberations, and recommendations to the committee are contained in its complete report, found in Volume II, Supplementary Papers. The committee has benefited greatly from the panel's work. In what follows, the committee summarizes its own views about the present and future roles of NPPs in the VA, especially as related to the central issue of physician requirements. DEFINING THE NPP AND THE FOCUS OF THE ANALYSIS With the concurrence of the committee, the NPP panel sought to develop a typology that would differentiate nonphysician providers according to the nature of their interaction with physicians in VAMC PCAs. To be included were all providers whose activities have a direct effect on physician workload. These analyses led to the definition of three groups of nonphysician providers: Category I—Administrative/Operational Support Personnel, which includes clerical support, medical records clerks, patient transporters, and others. Category II—Clinical Complementary Service Personnel, which includes nurses, podiatrists, optometrists, and such allied health professionals as occupational therapists, physical therapists, and speech therapists, among many other service personnel in the allied health technologies. Category III—Direct Medical Service Personnel, which includes PAs, NPs, clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), psychologists, and clinical social workers. Within this typology, it was hypothesized that personnel in Categories I and II boost physician productivity by functioning as "complementary inputs" to the physician in the production of workload in the PCAs. (See Volume II, Supplementary Papers, for a discussion of complementarity in this context.) It was hypothesized that providers in Category III increase productivity at the VAMC by directly substituting for the physician in certain designated tasks. Although these tasks are performed under supervision of the physician, the latter need not always be in the physical presence of the Category III provider and thus can concentrate on other patient care services. Moreover, it was hypothesized that in a VA health care system of the future that gave increasing emphasis to ambulatory and long-term care, Category III

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Physician Staffing for the VA: Volume I providers—particularly PAs and NPs—could function satisfactorily in expanded roles in ways that would affect physician requirements. In light of these factors and with the approval of the committee, the panel decided to focus almost entirely on Category III providers, designating this group as "nonphysician practitioners." Thus, throughout this chapter (and this report), NPP refers specifically to Category III providers. The committee (and the panel) realized, however, that a typology can take one only so far. To examine the hypotheses above, variables representing the interaction between each type of NPP and the physician should be entered in the production function (PF) equations (see chapter 4); the resulting coefficient estimates (with some subsequent sensitivity analyses, as illustrated in chapter 7), would allow an examination of the overall effect on physician requirements. Similarly, from such analyses one could derive estimates of the effect of NPPs in ambulatory care and long-term care settings. From the perspective of the expert judgment approaches to staffing, a similar strategy could be followed. Assumptions about the availability of NPPs could be built into the Staffing Algorithm Development Instrument (SADI) and the Detailed Staffing Exercise (DSE), thus allowing estimation of physician requirements conditional on the assumed distribution of NPPs in the VAMC. But as the committee realized early on, there were some basic roadblocks to proceeding this way. The main problem was that current VA data systems do not permit one to obtain Full-Time-Equivalent Employees (FTEE) allocated to PCAs for most of the nonphysician providers listed above. Only for nurses (based in the VAMC nursing service), psychologists, and social workers are data on FTEE by PCA available presently on a national basis. [For these three, the VA has designated distinct cost centers in its Cost Distribution Report (CDR); see chapter 4.] For all others, including PAs and NPs, one can obtain total FTEE by VAMC, but not by PCA. Since the PFs are PCA specific, all variables used in them must likewise be PCA specific. Instead, a type of "second-best" approach to analyzing NPP effects in the empirically based models was pursued. In particular, SUPPORT/MD, a PCA-specific variable appearing in a number of PF equations, includes (among the components of its numerator) the total PA and CRNA FTEE in the PCA; depending on the policies at a given VAMC, it may also include NP and CNS FTEE. Similarly, the PCA-specific variable NURSE/MD may include (in its numerator) both NP and CNS FTEE. However, the numerators of both variables will also contain much FTEE not pertaining to these four NPPs. Hence, the statistical performance of SUPPORT/MD and NURSE/MD can provide some very broad indications of the impact of NPPs. However, these variables can yield no direct insights into the specific productivity contributions of PAs, NPs, CNSs, or CRNAs. In addition, the committee found that many observers of, and participants in, the VA health care system had views about the future roles of NPPs; but

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Physician Staffing for the VA: Volume I there had been little systematic collection and analysis of information relevant to this large issue. In response, the committee directed the NPP panel to review the existing literature and to conduct one or more field surveys that would yield new data and insights. INFERENCES FROM THE NPP SURVEYS The first two surveys, conducted in late summer of 1990, were of selected NPPs and their supervisors in a stratified random national sample of VAMCs. The NPPs examined were PAs, NPs, CNSs, and CRNAs; because the time allocation across PCAs, and thus patterns of patient care, for psychologists and social workers can be inferred from existing CDR data, these two provider types were not included in the surveys. The universe of VAMCs was stratified by VA region and RAM Group (see chapter 4 for definitions); of the 40 VAMCs contacted, 36 responded. The number of responding NPPs are as follows: PAs, 138; NPs, 67; CNSs, 57; and CRNAs, 26. A total of 172 supervising physicians responded. Detailed analyses and discussions of these data, along with the questionnaires from which they were derived, are included in the NPP panel report. The committee found the following inferences particularly noteworthy: NPPs are able to allocate their time across PCAs, and to various activities within PCAs, in a comprehensive and coherent fashion. Hence, the committee concludes that it is feasible, from the NPP perspective, to collect FTEE data at the level of detail required by the empirically based models. On average, almost half of a PA's time is presently spent in the inpatient PCAs. Just under 40 percent is allocated to ambulatory care, and less than 10 percent is devoted to the long-term care PCAs of nursing home and intermediate care. Compared with PAs, NPs currently spend less time in inpatient care (under 30 percent, on average), more time in ambulatory care (about 47 percent), and more time also in long-term care (about 15 percent). Thus, neither PAs nor NPs devote a significant percentage of time, on average, to long-term care at present. Although there are multiple interpretations of this result (see the NPP panel report in Volume II, Supplementary Papers), one plausible inference is that traditional patterns for using NPPs—particularly PAs—persist even as workload patterns begin shifting toward ambulatory care and long-term care. Another possible inference, of course, is that present workload levels simply do not require a high percentage of NPP time allocated to long-term care at the facilities surveyed.

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Physician Staffing for the VA: Volume I The committee notes that because only 36 VAMCs were involved in the survey, it was not feasible to use the responses to construct NPP-specific variables for the PFs, which are estimated using the universe of VAMCs relevant to each PCA. In remarks volunteered by the NPPs and their supervisors on the survey forms, there were some recurring themes: • Many NPPs said that they were utilized below their trained potential, either because physicians did not know how to use them for the range of tasks they could perform, or preferred not to do so. A number of PAs and NPs wrote that they were hampered particularly by a lack of prescribing privileges. (The committee notes, however, that the VA has recently initiated pilot programs in which selected PAs are permitted to prescribe drugs according to specific protocols.) Several NPPs indicated that they operated with maximum flexibility and independence—which the committee interprets to mean, with very little physician supervision. The supervisors were generally pleased with the quality of care rendered by NPPs and urged the VA to consider expanding their use, particularly in long-term care. Most indicated that competent physician supervision is important, and a few noted that they simply did not have time to supervise NPPs properly. An undercurrent in both the NPP and the supervisor responses is that all participants need to be better educated about the current and potential roles of these practitioners. The committee and the panel decided that these perceptions should be investigated more systematically, with a focus on those responsible for clinical decision making at the VAMC. Thus, a third survey, directed at the chiefs of staff (COS) at the 40 VAMCs in the original sample, was conducted in January 1991; 34 COS responded satisfactorily. The questions pertained to policy issues regarding the utilization of NPPs (how the VAMC sets its policy, what role the state practice acts play within the facility policy, and whether the VA should have a comprehensive national policy); the potential roles for practitioners in inpatient, ambulatory, and long-term care; policies the VA could adopt to increase the utilization of NPPs in these three areas; and the issue of continuing education for physicians and NPPs. A thorough analysis of their responses is contained in the NPP panel report (Volume II, Supplementary Papers). The committee took note of the following points: The majority of the responding COS believe that the VA should do more on a national level to support and encourage the appropriate utilization of

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Physician Staffing for the VA: Volume I NPPs. Many expressed both a frustration with the restrictiveness of state practice acts and a need for additional clarification from VA Central Office on the scope of activities recommended for these practitioners. When asked if the VA should develop a national policy regarding the use of each NPP, 75 percent responded in the affirmative. They urged that such a policy should more clearly delineate the functional roles and responsibilities of the NPPs and their physician supervisors. They favored a policy that would clarify the relationship between the provisions of the practice acts, the practice standards of each NPP, and what is permissible inside a VAMC. Most COS explicitly advocated flexibility in the application of a VA national policy at the facility level. Many of the COS urged that PA/NP duties be expanded in several particular areas. The most prominently mentioned area was drug prescribing. More than a third of the respondents volunteered that selected practitioners should be granted privileges to perform this function. The committee feels that it is in no position at the moment to address the advisability of any particular innovative function for NPPs. However, the committee believes that the VA should actively investigate the appropriateness of such functions, and of expanded roles for NPPs in the patient care process, when there is significant supporting evidence. Virtually all responding COS supported the use of NPPs in inpatient settings, and a number gave detailed responses about routine as well as innovative ways these practitioners could be further deployed in ambulatory and long-term care. The majority of the COS felt that staff physicians needed education about the appropriate use of NPPs. A number of approaches were suggested, but most said that a facility should develop an ongoing in-service program. Several COS suggested that each incoming staff physician be oriented to the use of NPPs at that facility. CONCLUSIONS AND RECOMMENDATIONS The committee's views, focusing on four nonphysician practitioners (PAs, NPs, CRNAs, and CNSs), are summarized below. Integration of NPPs into the Physician Staffing Methodology The committee believes that the degree to which these four types of NPPs are utilized has a direct effect on physician requirements. Therefore, the committee urges the VA to account more precisely for the influence of these NPPs, in both the empirically based and the expert judgment approaches to physician staffing, by incorporating the following:

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Physician Staffing for the VA: Volume I For the empirically based models, the VA should establish CDR cost centers for each of these NPPs. At present, the total FTEE of each type of NPP is available at the facility level but not allocated across PCAs. If each of these NPPs was given a designated CDR cost center—as is the case presently for physicians (by specialty), nurses, psychologists, and social workers—it would be possible to analyze them explicitly in the PF and the inverse production function (IPF) variants of the empirically based models. At present, these NPPs are reflected (indirectly) in the PF and the IPF equations only through their inclusion in the SUPPORT/MD and NURSE/MD variables, as noted earlier. For the expert judgment models, NPPs are already explicitly included (see Figures 5.1 and 5.2). However, in subsequent versions of the SADI and the DSE that the VA may choose to create, these NPPs should be recognized with greater specificity. In particular, the assumed number of each NPP in every PCA should be specified in these staffing instruments. Continuing Education for Physicians and NPPs From the analysis of the NPP panel survey data and commentary, the committee concludes that the utilization of these practitioners is more dependent on the attitudes and knowledge of individual physicians than on the training and the clinical skill level of the NPP. Before the VA can utilize NPPs in an efficient manner consistent with quality care, education programs for VA physicians must be established. The committee recommends that these be conducted on an ongoing basis, first with a centralized program for senior VA management staff, then with programs established at every VAMC. To support this recommendation for continuing education, the committee recommends that the VA also Pursue and establish, wherever possible, academic affiliations with NPP training programs. Not only would this provide physicians with first-hand experience with the strengths and limitations of these practitioners, it would stimulate NPP recruitment. Require and actively support the participation by NPPs in their own continuing education, as another way to increase physician confidence in these practitioners. The committee feels that this would allow the NPP not only to maintain current skills, but to learn new techniques within any given specialty or setting. This would permit the NPP to continue to benefit from the clinical expertise within the VA. But by also encouraging the NPP to pursue education and training at outside sites, the VA would establish a mechanism that allows staff physicians to learn (indirectly) about innovative uses of NPPs.

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Physician Staffing for the VA: Volume I The committee understands that such affiliation and continuing education programs now exist in various forms at some VAMCs. The committee recommends that the VA explore their establishment across the board. A National Policy for Appropriate Utilization of Npps Because physician knowledge and attitudes regarding NPPs vary greatly across (and even within) VAMCs, there is wide variation in the activities actually performed by NPPs. This view was underscored by the survey results discussed earlier in this chapter. From these, the committee concludes that much of this variation in NPP use is due to variations in a facility's or a physician's interpretation of the NPP role, response to various state regulations and licensing arrangements, and the quality of organized supervision. An underlying factor is the absence of a comprehensive VA national policy that establishes clear guidelines for all NPPs. For PAs and CRNAs, national guidelines presently exist that serve to define their general scope of practice by listing specific permissible functions. The activities that may be delegated to the individual NPP are, in fact, determined entirely at the VAMC level by its clinical executive board. This board approves the specific terms of the clinical privileges held by each practicing NPP at the facility. The committee applauds the efforts undertaken thus far to establish national guidelines for these two NPPs, especially the relatively detailed policies developed for PAs. The committee urges the VA to develop explicit national policies on the appropriate use of all NPPs through a careful evaluation of existing evidence on the efficiency and quality of their clinical practice. These policies should be reviewed and revised periodically, should be consistent across the system, and should permit individual VAMCs the flexibility to tailor their use of NPPs to local conditions in ways that promote the quality and efficiency of VA health care. National VA policies for each NPP should establish explicit guidelines for the practitioner's potential roles, responsibilities, and appropriate utilization in the VA system. The policies should encourage the appropriate use of NPPs by explicitly addressing, for each type of NPP, a range of expected requirements: training and skill level, continuing education for the NPP, physician supervision, peer review, continuing education for staff physicians, and administrative procedures for allowing certain practitioners with advanced training and experience to perform innovative functions under physician supervision. For each type of NPP, the national guidelines could include a specific list of functions for which there is evidence, in each case, that a well-trained and supervised practitioner can render care of appropriate quality. The national

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Physician Staffing for the VA: Volume I guidelines would also provide each facility with the autonomy to determine additional functions such as drug prescribing, which could be performed by NPPs with specific levels of training and experience. These additional functions would be performed under physician supervision and could, in addition, require the establishment of a specific supervisory structure (e.g., team conferences, protocols) to monitor the quality of care. The aim here (and a difficult one) is to promote a strong, coherent VA national policy on NPP use, while preserving the concept that individual VAMCs have both the autonomy to explore innovative uses of NPPs and the responsibility to ensure that the quality of care is protected through appropriate supervision. In the course of establishing these policies, the VA should seek to clarify whether the ''federal enclave'' doctrine exempts the individual VAMC from the clinical provisions of its state medical practice act, so that each may establish unambiguously its own NPP practice policies under guidance from VA Central Office. Once this principle is ruled upon, the VA will be in a stronger position to promulgate its own positions on innovative uses of NPPs that are currently forbidden by many states. As knowledge about the appropriate and effective use of NPPs continues to grow, the VA should periodically and thoroughly review its national policies on the use of these practitioners. As analyses emerge indicating that specified functions can be performed efficiently by NPPs with no anticipated loss in quality, the VA should incorporate these functions in its guidelines. This information should be communicated promptly to chiefs of staff, service chiefs, and clinicians (to the latter through the continuing education programs recommended above). Similarly, when the weight of evidence indicates that the NPP's performance of a function does not promote efficiency or quality, the function should be removed from the guidelines. The importance of this recommendation is that these guidelines (as they are updated over time) are expected to be a major factor in the determination of the privileges accorded by the VAMC to each practitioner. Additional Studies and Analyses The committee concludes that much was learned from the NPP Panel's surveys. A number of particular research questions have been suggested, and these should be pursued by the VA in broader-scale analyses. The committee recommends that the VA establish research projects to examine extensively the different systemwide uses of these four types of NPPs. At present, there are numerous opportunities to observe NPPs in various settings, for various functions, in varying degrees both inside and outside the VA. The VA should take advantage of these "natural experiments" to evaluate

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Physician Staffing for the VA: Volume I the appropriate (and inappropriate) uses of NPPs under a variety of practice conditions. As evidence from these evaluations accumulates over time, the VA's ability to establish appropriate NPP policies will be greatly enhanced. REFERENCES Becker, D.M., Fournier, A.M., and Gardner, L.B. 1982. A description of a means of improving ambulatory care in a large municipal teaching hospital: A new role for nurse practitioners. Medical Care 20:1046-1050. Cromwell, J., and Rosenbach, M. 1990. The impact of nurse anesthetists on anesthesiologist productivity. Medical Care 28:159-169. Mendenhall, M.C., Repicky, P.A., and Neville, R.E. 1980. Assessing the utilization and productivity of nurse practitioners and physician's assistants: Methodology and findings on productivity. Medical Care 18:609-623. Office of Technology Assessment. 1986. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis. Health Technology Case Study No. 37. Washington, D.C.: U.S. Department of Commerce, National Technical Information Service. Spisso, J., O'Callghan, C., McKennan, M., and Holcroft, J.W. 1990. Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. Journal of Trauma 30:660-665.