Lots of docsPhysicians compete with advanced practice nurses for patients

Illustration by Renee Montgomery and Malcolm Garris

LOTS OF DOCS
Will competition for patients increase between
advanced practice nurses and physicians?

By Barbara Bronson Gray, MN, RN

The oversupply of physicians could put advanced practice nurses into a high-stakes game of tug-of-war as competition heats up. Yet as better cost, quality, and outcomes data become available, some experts predict nurse anesthetists, nurse-midwives, nurse practitioners, and clinical nurse specialists could be the ultimate winners.

The Pew Health Professions Commission says the country has between 100,000 and 150,000 physicians too many out of a total of 700,000 practicing physicians. And the supply is growing: About 17,000 new physicians graduate from medical schools every year. Similar estimates have been made by the Council on Graduate Medical Education, the Bureau of Health Professions, and the Physician Payment Review Commission.

A study in the March 6 issue of the Journal of the American Medical Association suggests that physician unemployment and underemployment are on the rise and certain specialists are having difficulty getting a first job after their residency. Some experts predict the supply of physician specialists will outstrip demand by more than 60 percent by 2000.

As of March, advanced practice nurses represented 6.3 percent of the total registered nurse population, according to the Division of Nursing of the U.S. Department of Health and Human Services. There are almost 54,000 clinical nurse specialists, 71,000 nurse practitioners, 6,500 nurse-midwives, and 30,000 nurse anesthetists nationwide.

It’s hard to predict how the oversupply of physicians will ultimately affect advanced practice nurses, but many nurses are already reporting an impact. Dennis O’Leary, CRNA, does office-based anesthesia for plastic and reconstructive surgeons in Los Angeles County. Ten years ago anesthesiologists shunned medical-office anesthesia, but now O’Leary finds they’re eager for the work.

"Anesthesiologists will initially lower their fees to get into a medical office and then their fees will gradually rise. In fact, some anesthesiologists charge less than I do," O’Leary said. To compete, he has to be more flexible and more available for the surgeons. "I just try to outwork them by doing more than they do, treating the office staff well, and assisting the circulating nurse. I let my work speak for itself," he said.

Certified nurse-midwife Pixie Elsberry, RN, director of midwifery at North Central Bronx Hospital in New York, said midwives are feeling intense competition, especially from obstetrical residents. "We’re hustling to hang on," she said.

New York state is part of a Health Care Financing Administration demonstration project that is paying hospitals $400 million to stop training physicians in certain specialties. Elsberry said that such initiatives are making physicians nervous and funding for midwifery programs is being cut to help ensure that medical residents will find work after they graduate.

Some midwives are also having trouble getting or maintaining admitting privileges to hospitals. "Physicians are taking care of physicians as all this plays out," Elsberry said. "One obstetrics residency chairman is very clear that he wants to be sure his residents have a job, so nurse-midwife jobs will be eliminated."

Yet some hospitals and health plans find advanced practice nurses are popular among patients and decrease costs without lowering the quality of care. Kimberly Patamia, spokesperson for the Washington-based American College of Nurse-Midwives, said Columbia Presbyterian Medical Center in New York offers patients seeking primary care services the choice of a nurse practitioner, midwife, or physician; most are opting for the nurse-midwife or nurse practitioner.

Ed O’Neil, PhD, associate professor of family community medicine at University of California, San Francisco and director of the Center for the Health Professions in San Francisco, said focus groups show that consumers have an increasing interest in getting health care from advanced practice nurses. "Forty percent of our focus groups don’t mind getting primary care from a nurse practitioner," he said.

O’Neil said that CRNAs have become the dominant anesthesia providers in some institutions, and those healthcare systems are reluctant to bring anesthesiologists in. "The data around CRNA practice quality is absolutely compelling," he said.

Yet O’Neil is seeing turf wars between physicians and advanced practice nurses heating up. "We’ll see a big backlash from physicians," he said. "There’s already a serious rollback bill in New York, trying to limit nurse practitioner scope of practice. We’re beginning to see more testiness by physicians."

Some experts see competition as a complex issue. Where advanced practice nurses are practicing in place of physicians—such as in anesthesia or obstetrics—the tension is the most intense. But where nurses can extend the reach or increase the efficiency of physicians in a capitated environment, they are in great demand by physicians.

For example, nurse practitioners can increase the efficiency of physicians by seeing patients or providing services that range from patient education to suture removal. Susan Wysocki, NP, RN, president of the National Association of Nurse Practitioners in Reproductive Health in Washington, said, "Many nurse practitioner positions have been created to deal with capitated reimbursement due to the volume required to keep pace with rising practice costs."

Sometimes a primary care practice hires a nurse practitioner who specializes in a particular area to give the medical practice an added edge against the competition, Wysocki said. Mary Cannobbio, MN, RN, a lecturer and student recruiter at UCLA School of Nursing, said she gets calls from physicians asking for nurse practitioners to free them up to see more patients. "For them, the nurse practitioner is an asset to their practice," she said.

Cannobbio is seeing more interest in hiring clinical nurse specialists than she had in the past few years. Hospitals and health systems are finding that CNSs can play a valuable role in educating staff and supporting patients and families.

But in geographical areas that are saturated with physicians, some nurse practitioner graduates are having trouble finding full-time work with benefits, Cannobbio said. "Our nurse practitioner program graduates are getting hired per diem or part time. Some are working two to three jobs, often without benefits."

Physician assistants (PAs) also compete for jobs with advanced practice nurses and physicians. For PAs, jobs are hard to find in the desirable metropolitan areas, said Nancy Hughes, vice president of information and research services for the American Academy of Physician Assistants in Alexandria, Va. "We point out to PA program grads that there is a high demand for PAs. Are the jobs all in nice cozy suburbia at a high salary? No."

There are 29,000 practicing physician assistants and 96 PA programs in the country, Hughes said. But physician assistants are not seeing a rise in direct competition with physicians, she said. "We don’t see competition between physicians and PAs, because they practice medicine as a team," Hughes said. But she does see fewer PA practicum sites because they are being taken by medical residents.

As physician oversupply plays out, nursing could end up having more in common with medicine than ever before. Nurses and physicians are increasingly becoming fellow employees. The pressure of the marketplace is pushing physicians to leave entrepreneurial practices and become employees in HMOs or similar organizations.

James Rodgers, PhD, director of the American Medical Association’s Center for Health Policy Research, said the nation has gone from having 25 percent of all physicians working as employees to almost 40 percent of practicing physicians now being considered employees. These numbers are conservative, he said, because they do not include physicians associated with Kaiser Permanente or other organizations in which physicians are counted as co-owners of the enterprise, but could also be considered employees.

Most experts think the competition between advanced practice nurses and physicians will rage for the next few years, but ultimately will subside as the overall demand for health care—fueled by population increases and the aging of baby boomers—increases.