Welcome to WNYPAA.org!

Looking Back, Looking Ahead

Ann M. Hoppel, Managing Editor

As Clinician Reviews enters its 20th year of publication, we ask your indulgence in a little bit of nostalgia. We’ve asked a panel of NP and PA leaders to reflect on how their professions—and the relationship between the two—have evolved in the past two decades, as well as what is different about the health care system overall.

The panel includes our PA and NP Editors-in-Chief, Randy D. Danielsen, PhD, PA-C, DFAAPA, and Marie-Eileen Onieal, PhD, CPNP, FAANP; American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, American Academy of Physician Assistants President Stephen H. Hanson, MPA, PA-C; and two clinicians who have been members of the CR Editorial Board since the very first issue, Freddi I. Segal-Gidan, PA, PhD, and Angela M. Staab, MN, ANP/GNP-C.

How has your profession grown in the past 20 years?
Swanson: We were pretty much a well-kept secret for many years, and the laws started to change in the ’90s and recognized NPs legally—gave them legal authority to practice in varying levels. There was also time to start doing studies on quality and cost-effectiveness. Once you can get data like that, your profile will go up. People will realize that you have value that they want to take advantage of.

Onieal: In the 1990s—in Massachusetts, anyway—we got prescriptive authority for all advanced practice nurses. We started to see more acceptance of the NP as a member of the primary health care team…. We had been around awhile, and we started to see data to demonstrate the safety and the quality [of NP care]. And we started to see a movement toward and then fruition of reimbursement for NPs and NP services. So it was like this watershed of successes after decades of trying to get recognized, to get reimbursement,to get prescriptive authority…. The groundwork was done in the later ’60s/early ’70s and into the ’80s. Then in the ’90s, it was sort of the reaping of the seeds that had been planted.

Hanson: Just looking at some of the statistics: In 1990, there were about 24,000 PAs. Now we have about 73,000. PA programs went from about 110 to 148 accredited programs. We went from 40% female to 62.8% female…. I don’t think anybody could have predicted the explosion of specialty practice for PAs.

I think everybody realizes how important PAs are to the health care system. We’ve reached critical mass; there’s one PA for every 10 physicians in America now. Within five years, there will be 100,000 of us. So I believe we’ve reached critical mass as a profession, and we’re saying, “Wow, PAs are fulfilling so many roles within the health care system.” The demand has really kept up with the supply. But it’s important to ensure that funding for medical education through mechanisms such as Title VII ... also keeps pace with our nation’s growing needs for health care professionals.

Segal-Gidan: We haven’t succumbed to the changes in the health care system; we’ve adapted. I think both professions have. We’ve provided care to a lot of people, in a huge variety of settings—geographic settings and medical settings. And the people we’ve provided care to have largely gotten good care. We’ve really been able to partner with physicians to provide care on the grassroots level; we’ve done really well on the patient delivery aspects—what we really want to do. I think we’ve gotten mucked up in the administrative and political parts and haven’t made enough progress in those areas.

Another big change is that while we’re trained in the primary care model, as the need for PAs in non–primary care settings has grown, we have been able to grab those opportunities. That has led to some significant changes, and some confusion and controversy, as to the profession’s identity.

Where would you like to see your profession 20 years from now?
Swanson: I’d like to see us practice with no barriers. I’d like to see us have to spend very little time and money on legislative activities that give us the ability to practice our profession. I would like to see us spending more time on doing outcomes studies and quality studies, and developing approaches to primary care problems and chronic disease problems and health, wellness, and prevention.

Danielsen: Something that we’ve done a really poor job on is practice research—research on how PAs practice, cost-effectiveness of practice, their role in the health care system. Nursing and NPs have done extremely well at it. Their movement into PhD-level nurses doing research, decades ago, has served them well. We [PAs] didn’t do that, and we should be doing that. I’d like to see some joint efforts between NPs and PAs looking at these issues.

Onieal: In another 20 years, we should see what we see here in Massachusetts—that nationwide, NPs are on the preferred provider lists for all insurance companies, whether they be public or private. That words like “supervising” and boards of medicine and pharmacy having control over nurse practice acts are gone. And that NPs and PAs … are able to function to the full extent of their capabilities.

We’re going to need NPs and PAs to provide appropriate and timely health care to the population, because everyone will have “insurance.” Everyone will have appropriately unfettered access to primary health care. Notice I said “primary health care.” I didn’t say “unfettered access to the emergency department.” And I think we’ll go back to the days when the emergency department was where you went when you fell out of a tree or when you forgot to move your hand away from the saw blade. Not because you’ve had a rash for three weeks and there’s no place else to go.

Segal-Gidan: I’d like us to be able to stand on our own. We were bred from physicians and the established medical community, but we are our own profession and I hope we can stand on our own and not be so tethered to medicine. We’re getting there, but 20 years ago I was hoping that now we would be there.

Personally, I would like to see PAs meet the huge and growing unmet need for good basic geriatric care. I think it’s a huge opportunity. But I don’t know whether the profession is interested in that, because the incentives aren’t there….

I also hope we, as a society, are more rational in how we use our resources. If we’re going to continue to work in a world of reimbursement for services rather than flat fees or some other payment structure, I think we need to identify those parts of medical care that can be provided by whomever (PA, NP, or other licensed provider) and define what the cost is for that service. Then whatever the cost is for that service, whoever is licensed, trained, and able to provide it, that’s what you get paid. And if there are things that only a physician can do, because a PA or NP or midwife or nurse anesthetist can’t do that, then they get that [fee]. Otherwise, what’s the incentive? If you’re a doctor doing something that someone with lesser training can do, why should you get paid more?

Hanson: I just believe that we’re the right solution to the problem. The problem is quality, affordable, accessible health care in all aspects. PAs have always been dedicated to that. And so looking to the future, looking at health care reform, looking at what our nation needs, I think we need to incentivize physicians, PAs, and NPs to choose primary care specialties. We need people working in rural and medically underserved areas. With health care reform, we need to make sure that we help PAs, physicians, and NPs choose primary care.

PAs are coming out of school with a significant debt load, and I’m sure that’s true of all the medical and nursing schools…. PAs practice medicine because they really love what they’re doing. But we all have to make a living at what we do. I think there are ways, with loan forgiveness and incentives through reimbursement, that we can help some people make decisions to choose primary care over a surgical subspecialty.

Staab: My concern is NPs and PAs are getting really good at primary care—we’re the best thing that happened to primary care, because we don’t overstep our bounds and we can treat most of the chronic diseases—and of course the wellness stuff we do really superiorly. But we need to stay that way. And every day, we’re being pushed to see more and more patients faster and faster. We will become just like what we never wanted to be, if we don’t watch it and put our foot down. That’s what we have to maintain. Younger people and those who are getting pushed into these practices where they’re seeing 25 and 30 patients per day, they’re becoming just like the physicians were, as far as speed, and not doing the things that NPs and PAs have earned their reputation doing.

This younger generation doesn’t realize how hard people worked to get them prescribing abilities and reimbursement. They worked many, many hours, went to lobbyists and paid PAC funds just to get the support they needed to become the more independent practitioners that they are today. So I hope that they will maintain a little idealism as a thank you to the PAs and NPs who preceded them, for getting them where they are. I don’t want them to ever lose sight of what their true reason for being in the health care system was when we started it.

How has the relationship between PAs and NPs evolved over the past two decades?
Staab: You know, NPs and PAs were just about at each other’s throats early on. The NPs figured they were the only ones that could do primary care; at that time, PAs didn’t have to have any degrees and they were going to school to get a certificate. Some of the programs were as short as three months. Because the NPs had to be a nurse first, we thought we were superior. Then when Duke and the other larger universities started turning out PAs with degrees who were really good in primary care, they proved themselves to the nurses and that’s when NPs and PAs saw each other as comparable in terms of care….

There was a PA conference in North Carolina [in the mid-1990s]. About 60 of us went, but there were probably three NPs who believed the PA conference had something for them. At that time, you were being told, “You need to go to an NP conference” or “You need to go to a PA conference.” But you didn’t need to mix and match.

Clinician Reviews was one of the first groups to say, “NPs and PAs can do a lot better if they get together and support each other than if they each try to make their own road alone.” Together, we can be very powerful. It was a big deal, because NPs and PAs hardly talked before that.

Danielsen: We’ve made huge inroads in the past 20 years…. I’m on the board of the nursing school here in town and I’m always asking them, “Do you get a copy of Clinician Reviews?” in the NP program, and they do. I’m seeing, as a result of that, a lot of interprofessional communication, particularly as it relates to CME/CE and discussions about practice.

It’s just something that has occurred because both professions are now better known and we interact with each other more now than we have before. There are some places, like Mayo in Scottsdale, where they have a combined group of NPs and PAs that meets once a month. And that is something that wouldn’t have happened in the ’80s.

Onieal: Thankfully, over the past 20 years, we have become more collegial than we were. Our lack of collegiality in the past was based, in my opinion, on the fact that lots of NPs didn’t know any PAs, didn’t work with any PAs. So I think in the early days we didn’t know who each other were….

I think too that as the years have gone by, NPs and PAs have been much more calm about agreeing where we disagree. NPs want total autonomy. Some PAs don’t. Some PAs hate the word independent—because, they say, “I’m always going to need my colleagues.” And I say, you’re going to need them, but we don’t want to be mandated to have them. There’s a difference. But I think we have stopped fighting each other in some instances.

Segal-Gidan: I have a little bit of a skewed view because California is different. One reason is that we have a program that trains NPs and PAs—the only program in the country, I think, that is joint. And we’ve had a pretty good working relationship with the NP profession, for a longer period of time.

The working relationships between PAs and NPs on a day-to-day basis are pretty good. But over time, different organizations have gravitated to the use of one or the other profession, and the roles have become more defined.

A lot of pediatric care, a lot of women’s health, is done by NPs. Their profession has gotten beyond a toehold in those areas, where PAs only have a small presence in gynecology and pediatrics. But PAs have developed more of a role in emergency rooms and in surgical specialties. I realize these are generalizations and may differ geographically. But the different professions have gravitated to different areas, and so the competition has decreased in some places.

Swanson: I can’t speak for anybody but myself in this regard. Everybody has a job to do, and there’s overlap. I think the difference is in how PAs view themselves and how NPs view themselves. NPs view themselves as independently licensed practitioners…. The only concern we have is we want our colleagues and the legislators to understand that we’re independently licensed professionals and not under the supervision of another profession. That’s probably the primary difference between PAs, NPs, and any other group—how we define ourselves.

Unfortunately, because of that, it does make it a little bit difficult for us to partner sometimes. We’re trying to distinguish ourselves as independently licensed providers. If we partner with PAs—and this is just my opinion, not a position statement—it makes it easier for people to lump us together as “midlevel providers.” And that’s a term that we absolutely abhor. I think, for me personally, that is the biggest thing. I would love to partner with PAs.

Hanson: I believe it’s gotten nothing but better. When it comes to patient care, we all care about the same thing. We want the best for our patients: We want the best health care, we want to deliver it in a quality way.

Right now, there are only three providers that can deliver health care directly in America as providers: physicians, PAs, and NPs. The sad reality is that if we cover everyone who is uncovered or uncompensated right now [in terms of insurance], we don’t have enough of any of us to provide that care. So we have to work together. We have to train more PAs, NPs, and physicians. We need to help them make the decision to stay in primary care.

What do you consider the most significant change for your profession in the past 20 years?
Danielsen: Obviously, the increase in the number of PAs—we’re fast approaching 80,000—is huge for the profession, but I think the biggest change is moving into specialties. It’s bittersweet. It portends for the future that PAs are going to be more utilized, more recognized, on one side. On the other side, they’re going to be more scrutinized, and it’s going to cause the educational community to start creating postgraduate residencies for them. A lot of people think that’s probably not good, but with the increased number of PAs in specialty practice, there is a public demand that they need to be competent in what they’re doing. So there needs to be some mechanism to let the public know and the patient know that these people are competent.

Onieal: I think the most significant change has been the true partnership of responsibility to primary care and to access to health care that has developed between NPs, PAs, and physicians. You see more collaboration and the recognition of a true interdisciplinary team for health care—and that’s things as simple as making sure people get their eye exams and dental exams. So it’s not just the PAs, NPs, and physicians. It’s the dentists, the ophthalmologists, physical therapists, occupational therapists. It’s much more of a team approach to keeping the population healthy. And I don’t think we saw that fully prior to now.

Segal-Gidan: Certainly, in the last 20 years the biggest change has been the significant number of PAs who have gone into non–primary care areas. I think 20 years ago we didn’t expect that.

The other big change, I would say, is the expansion of prescriptive privileges. The whole ability to prescribe, which is such an essential piece of medicine in the United States, was acknowledgment, at a government level, that you are legitimate. That sort of legitimized us for the public.

Swanson: It is probably getting prescriptive authority. Just because of the power that people imbue in someone who can write a recommendation on a piece of paper and hand it to you…. It sounds sort of trite. But I think in giving people prescriptive authority, that also says that you are recognized to manage patients and their problems, which does give a level of authority.

Hanson: The biggest shift is that the policymakers at the highest level are recognizing the contribution that PAs are making to the health care system. And being invited to the White House for an announcement on grant funding for community health centers [in December 2009] just highlights that recognition. We’re being recognized as part of the health care system; that’s a big shift, and it’s only been in the last couple of years.

Language supporting PAs and their role in patient-centered care is being included in more and more legislation. But we must work hard to ensure that recognition of our profession continues to increase.

What is different about the health care landscape today?
Danielsen: I started practice in the early ’70s; maybe it’s because I was such a new, young clinician, but I thought health care was wonderful. It wasn’t about money. Office charges were $4. A lot of people didn’t have insurance, so there was a lot of bartering.

But over the decades, a number of things happened. More physicians went into specialties and moved toward the city and out of rural health care. It became more about money and third-party payers. And that’s why the system is broken. And finally, the patient, the public, is starting to say, “This isn’t working.” I just think it’s little by little gone to big business, and it’s all because of the power of third-party payers and their lobbyists in Washington, DC.

Onieal: In the past 20 years, health care costs have become more visible. When I first received health insurance as an employee benefit, I didn’t pay anything for it. Or I paid such a little amount that it didn’t even faze me. Also, the push for all this preventive care wasn’t there. So now people are saying, “Hey, I’m paying X amount a month for my health insurance, mine and my spouse’s. I want something for that.” And the perception of want versus need has gotten sort of skewed.

The other night I was watching the news; just like in the ’60s, we’re talking about health care costs, and oh by the way, we’re also talking about the war. It doesn’t faze the government to spend millions of dollars a day [on that], and yet we’ve got how many million people uninsured. So I think people’s umbrage with the allocation of dollars has increased.

Swanson: While we rank really low among First World countries in many aspects of health care, the US in terms of cancer care is at the top. The USPSTF’s mammography recommendations notwithstanding—cough, cough—I think one of the things we’ve done very well is [cancer screening].

Another thing we’ve done well is to realize we’re in trouble and we have to think differently. My new hero is Elinor Ostrom from Indiana University, who won the Nobel Prize in Economics last year. She won it because she and her husband could see how bringing people together from disparate backgrounds to solve a problem was an extremely effective way of fixing things. In terms of health care, we may be trying to follow her model.... Unfortunately, politics always gets in the way. But I still feel it’s important to recognize that you have a problem and then decide you’re going to try to fix it.

Yes, we have a lot of problems. But I’m encouraged that we’re trying to acknowledge that. It gives me hope for humanity that we are more interested in helping each other than killing each other.