Managing Editor

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”