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Advanced Practice Nurses Critical to Increasing Access to Primary Care

There are more than 355,000 nurse practitioners (NPs) licensed in the US. NPs are nurses with masters or doctoral degrees and advanced training who can assess and diagnose patients, order and interpret diagnostic tests, and prescribe medicine with or without physician supervision. And they make up 43% of primary care providers in the US!

In 27 states and Washington, D.C., NPs can practice without physician supervision. In 12 states NPs can diagnose and treat patients independently but require physician supervision to prescribe. Supervision does not require that physicians be present in the practice; the providers sign a paid collaborative agreement and physicians may review charts and advise NPs via scheduled in-person and online meetings, and/or via telephone and email.

In “full practice” and “restricted practice” states, NPs can—and do—own and lead their own primary care practices or practice in schools, skilled nursing facilities, worksite and mobile clinics, in homes, and other settings. According to the American Association of Nurse Practitioners (AANP), 88% of licensed NPs in the US (70% in clinical practice) are certified and prepared in primary care with a focus on family, pediatrics, women’s health, geriatrics, neonatal, or psychiatric mental health.

In all 50 states and the District of Columbia, whether supervised or not, NPs hold prescriptive authority and complete more than 1 billion patient visits annually. And, they make up 25% of rural providers. 

This critically important healthcare workforce is professionally and personally committed, entrepreneurial, and collaborative. They partner with physicians even where the law does not require supervision. They are increasingly completing degree and training programs that prepare them for solo practice, and they refer patients to specialists when indicated, just as primary care physicians do. 

However, while the AANP and other nurse organizations, the Institute of Medicine (IOM), the National Governors Association (NGA), the Federal Trade Commission (FTC), the Bipartisan Policy Center, and the Veteran’s Health Administration (VHA) all support full practice for NPs, the American Medical Association (AMA) and many physician organizations do not. They respect, value, and rely upon NPs as part of physician-led care teams but worry that NPs lack sufficient training to practice alone and therefore may overprescribe or over-utilize resources. They also express concern that, because NPs do not complete multi-year residencies and complete only 500-720 hours of clinical training (physicians complete 10,000-16,000), patients’ safety and health outcomes may be threatened.

So, now what? 

In a perfect world, we would easily meet or beat a 2000-to-1 patient to primary care physician ratio (the bar for determining whether there is a provider shortage, factoring in health equity). But it’s not a perfect world. So, we seek mental health care via mobile apps because there are not enough providers in our insurers’ networks. We wait for health fairs to get free health screenings years too late. We click/dial an anonymous doctor to get a prescription. We have health crisis-level, maternal-child mortality rates because we can’t let go of racism and just listen. We allow kids to suffer when pediatric healthcare services are severely restricted and don’t create quality incentives for children’s care because it’s not profitable. We go bankrupt trying to pay for life-saving care.

So, in this wonderfully imperfect world, we must look to the primary care providers that patients/consumers trust most to help us extend our collective primary health care resources—with AND without physician supervision.

79% of U.S. adults say nurses have “very high” or “high” honesty and ethical standards, far more than any of the other 17 professions rated.

Gallup 2022 Trust Survey

We are already struggling with the effects of the growing primary care provider shortage (up to 180,000 by 2034, according to AAMC: 

  • Fifty-eight million (58M) Americans live in an area or belong to a population that is considered a primary care shortage area. 
  • Eighty percent (80%) of rural communities are shortage areas. 
  • Burnout among healthcare providers (53% of physicians and 60% of NPs) is creating record pre-retirement exits.
  • Health equity does not yet exist.

Active support of full and restricted practice NPs–and other advanced and alternative practice healthcare professionals is part of a multi-front solution to the health care crisis in America. Other solutions like (1) funding and creating more primary care residencies, especially in rural and low-income areas, (2) having state- and municipality- employed physicians supervise NPs to standardize supervision and fees, and (3) affordably, priced direct health care provided by primary care physicians and specialists (and even facilities) are also part of a long-term solution.

We at the Wonder Guild are enthusiastic supporters of safely, appropriately increasing practice authority so that highly skilled, committed, and compassionate nurse practitioners, physicians assistants, and other advanced and alternative practice providers can provide affordable, high-quality care wherever it is needed.

If you are an Nurse Practitioner or other advanced practice professional who is starting or growing your own practice, message me or join The Wonder Guild’s beta where we are testing a new way to help direct health care providers grow their practices by introducing them to thousands of individuals and families and employers near their practices.

Learn more about advanced practice/full practice authority for NPs with peer-reviewed research

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Direct Health Care Criticisms – And Why They’re Wrong

The American Academy of Family Physicians (AAFP) defines Direct Primary Care (DPC) as a practice and payment model where patients/consumers pay their physician or practice directly in the form of a flat monthly or annual fee, under terms of a contract, in exchange for access to a broad and enhanced range of primary care and medical administrative services, including real time access via advanced communication technology to their personal physician, extended visits, in some cases home-based medical visits, and highly personalized, coordinated, and comprehensive care administration and annual labs. 

The AAFP supports the DPC model, both for family physicians for whom the revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing; and for patients, who benefit because the contract fee effectively removes any additional financial barriers the patient may encounter in accessing routine care primary care, including preventative, wellness, and chronic care services. 

The model also extends beyond primary care where it is employed by specialists like dermatologists and psychologists whose services are not fully covered by insurance, by dentists who’ve established in-office plans, even by surgical centers and hospitals that allow patients to receive bundled treatments with discounts for pre-payment. At the Wonder Guild, we call this broader model Direct Health Care, or DHC.

And we are investing in developing a platform that scales and systemizes DHC so that it can serve millions of consumers nationally while providing support and resources to ensure physicians and providers can affordably, equitably meet 90%+ of their patients’ healthcare needs, remaining independent without becoming an island.

We love the potential of DHC but the model has its detractors. Here are their most oft-cited criticisms.

No, Direct Health Care won’t exacerbate the provider shortage.

Honestly, almost everything about the US healthcare system will exacerbate the projected provider shortage. But direct health care doesn’t even make the top 100. Here’s why. 

The American Association of Medical Colleges (AAMC) projects a shortage of 54,100 and 139,000 primary care physicians by 2033 (74,100-145,500 primary care physicians if barriers to access are removed and demand from underserved communities is included). Shortages among physicians in non-primary care specialties are expected to reach up to 60,300 (e.g. psychiatrists, surgeons, and ophthalmologists). These projections are based on:

  • Demand created by demographic shifts (the number of people in US aged 65+ is outpacing the number 18 and under)
  • Retirements (40% of primary care physicians will be 65+ years of age in the next 10 years) and burnout is contributing to an expressed desire to retire sooner than previously predicted.
  • Too few residencies, fewer medical students choosing to match to primary care residencies
  • Fewer medical school grads accepting primary care jobs (citing low pay), leaving nearly half of US primary care jobs unfilled
  • Maldistribution of physicians making shortages in rural and economically depressed regions more acute

Additionally, there is a deep misalignment of moral, professional, and financial interests between primary care physicians and health system and insurance leaders in the healthcare system.

  • 73% of physicians graduate with medical debt ($250,000 on average that takes 13 years to pay off)—and it takes providers an average of 13 years to pay off this debt.
  • 117,000 physicians quit in 2021—15,000 internal medicine physicians, 13,015 family medicine physicians, 7,330 pediatricians
  • 53% of physicians report moderate to severe burnout—90% of internists, 57% pediatricians
  • Top reasons for burnout: Volume of bureaucratic demands (61%), lack of respect from co-workers (38%), stress of treating COVID (8%)
  • 23% of physicians are depressed
  • 53% have a second job to earn more money and gain autonomy

So, it is by staying our current course that we ensure we have have a physician and provider shortage—and that the gap widens. The DHC model offers an opportunity to retain physicians and providers in the healthcare system where they can care for patients and take care of themselves.

No, DHC won’t remove physicians/providers from the healthcare system.

Many have bemoaned that direct primary care “takes primary care doctors out of the system”. Not true. The System is more than the sum of the assets and employees of governments, payers, hospitals, and health systems. We’ve lauded and welcomed the addition of retail clinics (Walgreens, CVS), concierge clinic chains (Amazon’s One Medical, Forward), virtual clinics (Maven), at-home urgent cares (DispatchHealth), and countless Medicare-focused wraparound service companies into the System even though they, of necessity, hire physicians and other providers away from traditional players, offering them higher pay and equity, leadership roles (e.g. Chief Medical Officer), flexible work, and lower administrative workloads. Is this more acceptable because these new players ultimately rely upon the old way of getting paid—payments from insurers or employers?

If we don’t embrace direct primary care (and, more broadly, direct health care) as simply another way to provide and access care, we not only risk continued loss of primary care physicians and providers but also the opportunity to truly align patient and provider interests. 

No, DHC will not reduce access to high-quality care.

In many cases health equity programs boil down to efforts to lower costs and increase access. If detractors accept that DHC does not physically remove physicians and providers from the system, their follow-up argument is that the smaller panel sizes managed by DHC physicians and providers has the same effect.

Under the DHC model, primary care physicians have an average panel size of 600-800 patients compared to primary care physicians in traditional practice with 2500-3000 patients. Prima facia it appears that smaller panel sizes further restricts access to care. But, a study by the University of California at San Francisco’s Center for Excellence in Primary Care determined that if a primary care physician does everything herself—screening, counseling, immunization, drug prescription, routine chronic care plus treatment of acute conditions—working 43 hours a week for 47.1 weeks a year, she can accommodate a maximum panel of 983 patients.

Studies have also shown that primary care physicians with 2500-patient panels do not have enough time to provide the guideline-recommended primary care (preventive, chronic disease, and acute care), even with team-based care. So, it’s more likely that direct primary care physicians’ panel size is optimal if the goal is to prioritize the provider-patient relationship in order to better identify health risk factors and provide timely, high-quality care at an affordable cost.

A recent study in the American Journal of Lifestyle Medicine found that direct primary care benefitted patients, providers, and employers. Patients get to spend more time with their doctors and rated their experiences more highly than those under traditional model. Patients, especially those who are uninsured or had a High Deductible Health Plan (HDHP), also saved 20% to 30% on annual healthcare spend by receiving 85% of their care in the low-cost DHC provider setting where they also had access to wholesale pricing on labs, imaging, and certain procedures.

Physicians experienced greater career satisfaction, less burnout, lower administrative burden, and gained financial stability. Employers saw a 54% reduction in ED claims, 25% fewer hospital admissions, and a 13% reduction in total cost of claims.

Another study by the Society of Actuaries and Milliman found that patients in the DPC models they studied reduced ED claims costs by 52%, inpatient costs by 8%, outpatient facility costs by 23%, urgent care costs by 19%, specialist visit costs by 15%, , home health care costs by 79%, and outpatient surgery costs by 5%.

So, if there is further restriction, it’s a restriction of lower-quality, higher-cost care and an increase in higher quality, lower-cost care.

No, DHC will not increase individual healthcare costs.

The crux of this argument is that direct health care will debilitate into expensive concierge care that is only affordable and accessible to the few and the affluent. To be fair, that is the state of the entire healthcare system–so expensive that 27M people are uninsured and receiving little or no care and 43M have insurance but skip appointments and prescriptions due to cost.

That said, the concierge practice model is purpose-built to serve affluent consumers and businesses that can afford to pay luxury prices for on-demand and often elective medical and health care services–on top of their platinum health plans. In contrast, DHC plans were purpose-built to serve consumers who may not have or be able to afford health insurance or is likely to hold a high deductible plan (HDHP).

The DHC model has a built-in set of checks and balances that uniquely position the model to meet the needs of patients and physicians and providers. Physicians and providers get a raise, largely due to eliminating billing, admin, and reporting costs. Patients get 85%+ of their healthcare needs met for an average price of $70/month. It’s affordable by any measure, but especially when you consider that the average salary for any person in the US is $59,428 (median $70,784). The cost of the average HDHP costs an individual 13.2% of their monthly income; the average cost of a DHC membership is 1.4%. Even if an individual held both a DHC membership and a HDHP, the entire cost would be easily offset by two, no-copay office visits or two labs run at wholesale prices.

Sure, DHC practices can and do charge more but there is a ceiling–the DHC consumer’s ability to pay. This makes DHC far more accessible to far more people than other approaches to paying for care.

But I’d be remiss if I did not acknowledge that if more physicians chose to practice independently–DHC or traditional–it might cause health systems and hospitals to pay more for contract staff and they might pass on those costs to insurers who will pass them on to individuals and employers and thereby drive up pricing.

[but also warns that direct primary care, with its smaller practice sizes, will further reduce accessibility by restricting provider capacity. Yes, anything that makes it harder for marginalized people to access care is bad. But, it’s not clear that this is true of direct primary care. After all, under the current, traditional practice model, health equity by any measure is still merely an aspiration. Black, Hispanic, and AIAN people fare worse than White people on every measure of health and health equity (Kaiser Family Foundation’s 2023 Report on Race Equity and Health Policy).]

No, DHC will not increase inequities. 

Additionally, when you consider factors that significantly limit access to and utilization of care—lower income, other cost-related barriers, lower rates of insurance coverage, limited access to comprehensive insurance coverage, fewer providers near home/work, racism—there are greater threats to the achievement of health equity:

  • Racism and implicit and explicit bias engender mistrust and discourage access by people who need care most
  • Acquisitions and mergers of, and between, health systems and hospitals (1,887 from 1998 to 2022) resulted in 2,000 fewer hospitals.
  • Feverish acquisition of primary care practices by private equity firms (484 in 2021 alone) has driven up primary and speciality care prices as much as 16% and per-patient expenditures by up to 10%—with no significant quality improvements. Care becomes more expensive and less accessible. Patients, especially those from poor and minority communities, have no ability to shop around and sub away to other providers when PE firms own 30-50% market share in 391 MSAs.
  • 70% of federally designated Health Professional Shortage Area (HPSAs) are in rural areas but 98% of medical residency programs are in urban areas. Slow growth in these residencies unfortunately coincides with increasing diversity among rural populations.

Yes, DPC will get us closer to health equity.

DHC is affordable enough that consumers can pay for it, even if they don’t have insurance or are underinsured. DHC memberships lower total healthcare utilization and cost of care by providing patients nearly unlimited access to their doctors. Physicians and providers can build small but thriving practices, even in rural or low-income communities, thereby removing transportation and convenience barriers for patients and incentivizing physicians and providers to locate practices in shortage areas. And, DHC, when coupled with expansion of practice authority for more diverse workforces like nurse practitioners, may also diversify the choice of providers available to a community.

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The Healthcare System is Broken and No AI, Startup, or Insurer Can Fix it

I’ve dedicated 15 years (and counting) of my life to contributing to the creation of a healthcare system that respectfully, equitably, and affordably provides timely care to every person who needs it. Since I began working in healthcare, I’ve led innovation, health equity, community health, communications, product/service design, digital health, value-based care, and clinical technology integration teams, strategies, and programs for insurers and integrated health systems and created their consumer content and marketing. I’ve loved the people and their commitment. Some of the work was amazing. But, as I sit here today—as the healthcare system continues to consolidate, patients, consumers, and primary care providers suffer, and we’re all doubling down on some version of the same strategies—I no longer believe any of it will fix what’s broken in American Healthcare.

Before you disagree, ask yourself these few questions. 

  • Is health care affordable for the average working person/family in America? 
  • In spite of hundreds of programs and campaigns, have we achieved health equity by any measure? 
  • What is the ratio of dollars spent to cost savings achieved when you tally up what you’ve spent on consultancies’ PowerPoints and Mural maps, startups’ apps and automation, tech companies’ cloud “infrastructure” and analytics, hospital rate increases, and fee-for-services firms that wrap around care for which you’ve already paid?

Now, consider this. 

Healthcare is too expensive.

Health Equity does not exist.

Black, Hispanic, and AIAN people fared worse than White people across every health and health care measure:

  • Having health insurance
  • Receiving mental health services
  • Flu vaccination
  • Life expectancy
  • Maternal & child mortality
  • Health screenings

Healthcare professionals are leaving (even dying) and care sites are closing.

  • 334,000 healthcare providers quit in 2021
  • 20% of current providers say they intend to leave due to burnout and frustration at not being able to spend time with and treat patients in accordance with their medical training and oath
  • 1 in 10 physicians have suicidal thoughts or have attempted suicide—300-400 die annually
  • 1,887 acquisitions between 1998 and 2021 have led to 2000 fewer hospitals, higher prices, and no significant quality improvements  

Health insurance offers little assurance of care.

  • Due to multiple lawsuits, private insurance may no longer cover preventive care 
  • Lawsuits, restrictive new laws, and consolidation restrict insurance coverage of abortion, birth control, and gender affirming procedures  
  • See Healthcare is too expensive

Spending too much time and money justifying and propping up the model.

And that’s just scratching the surface. I won’t pretend to have the perfect solution. However, I do believe that much of the solution lies in empowering individual physicians and providers—independent of, but partnership with, insurers, hospitals, health systems, and employers to make medically appropriate decisions—and in empowering and enabling consumers to directly purchase and utilize (not just have access to) affordably priced, timely, high-quality care from those who deliver and will be accountable for that care.

If you’ve got a solution, what aspects of that solution make it a fix for what’s broken in the healthcare system?

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Study: Affordable Healthcare Requires More Entrepreneurial Physicians

The only way to have true, affordable, healthcare is to increase the number of small business entrepreneurial family physicians in the medical market where the forces of consumer-patient demand, physician labor supply, transparent pricing and menu lists determine the true market price of medicine.

Read the study

Citation: McCutcheon, Robin & McCoy, D.. (2019). Physician-to-patient Direct Primary Care: Entrepreneurial Country Doctors Offer a NewMedical Business Model. Advances in Economics and Business. 7. 152-161. 10.13189/aeb.2019.070403.

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Direct Primary Care Saves Patients and Lowers Healthcare Costs

A study by the Society of Actuaries and Milliman reveals that DPC adoption by employers for their employees leads to significant reduction in patient demand for overall healthcare services (up to 19% less) and a statistically significant reduction in the frequency of emergency department visits (up to 53% less).

Read the study

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The Healthcare System is Spending Billions to Justify Effort, Not Results

In spite of spending trillions on health care and billions on quality improvement efforts, the US healthcare system has the worst health outcomes of any developed nation. A typical hospital spends nearly $6M a year and over 100K personnel hours compiling, creating, formatting, and transmitting quality reporting designed to demonstrate that they made efforts to get members to complete preventive screenings or otherwise close care gaps. Physician practices spent $40,000 and 785 personnel hours on quality reporting.

Read the study

Citation: Saraswathula A, Merck SJ, Bai G, Weston CM, Skinner EA, Taylor A, Kachalia A, Demski R, Wu AW, Berry SA. The Volume and Cost of Quality Metric Reporting. JAMA. 2023 Jun 6;329(21):1840-1847. doi: 10.1001/jama.2023.7271. PMID: 37278813; PMCID: PMC10245189.

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Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine (2021)

A 2021 study finds that the Direct Primary Care (DPC) model overcomes a major challenge in addressing health care costs–misaligned financial incentives–by directly aligning the interests of patients and physicians.

DPC was effective at lowering costs, providing a better patient experience, improving patient health outcomes (especially when integrated with Lifestyle Medicine) and in enabling physicians to practice the best medicine of their careers”.

Read the study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8504342/

Citation: Mechley AR. Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine. Am J Lifestyle Med. 2021 Apr 15;15(5):557-562. doi: 10.1177/15598276211006624. PMID: 34646107; PMCID: PMC8504342.

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What Will It Take to Heal Providers’ Moral Injury?

Much was made of physicians and other healthcare professionals leaving practice due to being overworked during and in the aftermath of the COVID-19 pandemic. In 2021, 334,000 healthcare professionals quit. Based on the many articles, surveys, and studies covering the topic, many did indeed leave because of the suffering that they and their patients endured as they grappled with the virus. But today, with a sharp decline in COVID cases and deaths and a system that is “back to normal”, 20% of physicians say they still intend to quit. 

Why?

A quick Google News search turned up 483 articles about physician burnout. Burnout is a syndrome defined by a state of of physical and emotional exhaustion due to chronic and prolonged workplace stress. The case for burnout among healthcare professionals during and following a pandemic is easily made. But there is evidence that healthcare providers’ struggle with the psychological, biological, and spiritual impacts of working in the US Healthcare System pre-dated the COVID-19 pandemic. 

The long list of challenges with the US Healthcare System—with its racism and inequities, profit-seeking, bureaucracy, high costs, low trust, and poor quality—date back decades. And COVID-19 was a tragedy that blasted away the last vestiges of “the System works”.

But it was in July of 2018, more than a year before COVID-19 was identified as a novel virus and nearly 2 years before it was declared a pandemic, that Drs. Simon Talbot and Wendy Dean published an article entitled “Physicians Aren’t ‘Burning Out’. They’re Suffering Moral Injury.” In the article, Talbot and Dean identify burnout as a symptom of the larger syndrome of Moral Injury.

The term was first coined in 2009 as part of a study designed to explore the occurrence in warriors and soldiers. Moral injury was effectively defined as a specific trauma that arises when people face situations that deeply violate their conscience or threaten their core values. 

Back then, post-traumatic stress disorder (PTSD) was the predominant diagnosis for soldiers who displayed symptoms of psychological, behavioral, and social stress. But the study authors explored whether, like physicians today, PTSD might actually be a symptom of moral injury.

For providers, the moral injury is the result of an “increasingly complex web of providers’ highly conflicted allegiances—to patients, to self, and to employers…leaving them unable to consistently meet patients’ needs, and resulting in profound impact on providers’ wellbeing (Talbot and Dean, 2018).” 

The problems are complex, systemic, and persistent. However, we know that no version of the American Healthcare System survives without healthy physicians and providers. The solutions will be compassionate, inclusive, sustainable, and they must, ultimately, function as a system within the healthcare system (@Robbie Pearl). 

So, where do start?

Talbot and Dean posited that the answer lay in “a truly free market of insurers and providers, one without financial obligations being pushed to providers, that would allow for self-regulation and patient-driven care…with goals aimed at creating a win-win where the wellness of patients correlates with the wellness of providers, thereby avoiding the ongoing moral injury associated with the business of health care”.

At the Wonder Guild, we are building a free-market solution to support physicians and providers who want to transition to a Direct Health Care model (a broader application of the Direct Primary Care model to physicians and providers in other specialties or those in hybrid models.

Our new product (still in stealth mode) centers on creating equitable care and outcomes for patients and wellness for physicians and providers and includes (1) an integrated set of services to support practice-building and growth and (2) all of the resources physicians and providers need in order to avail your patients of 95% of the care and services they will ever need. No upfront fees. No new EHRs, practice management, or revenue cycle management software to learn. No one telling you how to run your practice.

If you are a physician or other licensed healthcare provider who wants to grow your direct health care or hybrid practice, message me. I’d love to have you join our beta.