Made an appointment with your doctor lately? Chances are he or she was booked out for weeks or even months. New Hampshire, like the rest of the country, is feeling the strain of the shortage of primary care doctors-a situation that will only get worse as fewer students enter medical school to become general practitioners and Boomers start retiring in droves.
Helping to bridge that gap in the health care system are nurse practitioners (NPs) and physician assistants (PAs). Trained to provide most of the services of a doctor (see sidebars for definitions), but at a fraction of the cost, those providers are helping hospitals and medical practices meet the growing needs of communities.
While the median salary of primary care/family practice doctors nationally is $147,516 according to recruiter Physicians Search, nurse practitioners and physician assistants average $87,400 and $84,000 respectively according to the American Academy of Nurse Practitioners and Money Magazine.
It boils down to economics, says Richard Lorenz, a certified physician assistant at Androscoggin Valley Hospital Surgical Associates in Berlin. If you have two orthopedic surgeons and two PAs, it makes economical sense. Lorenz also does rounds at the hospital and takes emergency calls, helping his employers maximize their profits.
Lorenz was not surprised to learn his occupation was on the U.S. Department of Bureau of Labor Statistics' list of the 30 fastest growing occupations in the next decade and Money Magazine's recent list of the 10 best careers to have in a recession based on high pay and high job security. Physician assistants ranked fifth on Money's list, with a projected growth rate of 27 percent between 2006 and 2016.
Both nurse practitioners and physician assistants stress they are not competing with doctors. Lorenz describes himself as an extension of the physician and Lori Myers, a NP at Stratham Family Health, says she and her colleagues are needed as primary care providers are feeling the pressure to be more productive.
In NH, nurse practitioners have been around since the 1960s and now number about 145,000 nationally according to the American College of Nurse Practitioners. They are licensed to practice without doctor supervision and can open their own practices. Physician assistants emerged in the 1970s and must operate with physician supervision. There are an estimated 68,124 PAs in clinical practice and 12,000 students enrolled in PA programs, according to the American Academy of Physician Assistants.
There are about 1,500 licensed nurse practitioners in NH, says Lisa Carpenter, executive director of the NH Nurse Practitioner Association. Both the University of NH and Rivier College offer nurse practitioner programs. There are 387 licensed PAs in NH, up from 104 in 1993, according to Penny Taylor, administrator for the NH Board of Medicine. A program is available at the Manchester campus of the Massachusetts College of Pharmacy and Health Sciences.
Growth in both professions is steady. When physician assistant David Pendleton moved to NH a decade ago there were no job postings for physician assistants. Now if you go on the [NH Medical Society's] Web site, you can see 50 to 60 jobs posted, and that's just on our site, says Pendleton, who works at Catholic Medical Center in Manchester and is the immediate past president of the NH Society of Physician Assistants and an executive board member of the NH Medical Society.
Providing good health care requires a mix of providers. We've seen growth in the past five years of nurse practitioner [medical] practices, which have been hugely popular, Carpenter says of the emerging trend.
Wanted: General Practitioners
While nurse practitioners and physician assistants can be found in every medical specialty, perhaps the biggest demand is in primary care. They extend the primary care capacity in communities, says Mike Hill, president of the NH Hospital Association, adding they are also highly valued by hospitals.
That is because general practitioners are in short supply, choosing more lucrative specialties after being grossly underappreciated and under compensated, during the past decade by health plans, says Hill. Practically the only way they can survive at all is to be employed by a hospital. Hospitals that employ primary care doctors almost always lose money on it. They employ them because communities need them, he says.
And that's just one of many reasons why nurse practitioners and physician assistants are in demand. As reimbursed rates by insurance plans decrease, primary care doctors need PAs and NPs as they try to make up the difference in volume. Dr. Jeffrey Reisert of Tenney Mountain Internal Medicine in Plymouth started his practice in 2004 and cares for 1,100 patients a year.
He hired physician assistant Brittania McDonald two years ago and now sees an additional 500 patients, improving his bottom line and providing more time with patients who have complicated health issues. You need a certain number of people to meet the bottom line. PAs and nurse practitioners can see a lot of people, says Reisert, who also teaches at the PA program offered at the University of New England in Maine. PAs can do almost everything doctors can do, frankly. The clinical limitations are only that of the physician supervising them, he says.
And it's not only the Northern part of the state that is benefiting. The Seacoast has seen an influx of patients visiting emergency rooms and doctor's offices, partly from new residents moving from Massachusetts, as well as seasonal residents and tourists.
Bob Gaudreau, a nurse practitioner at Portsmouth Regional Hospital, says emergency rooms have seen a sharp increase in patients coming in with non-urgent medical needs. My job is to see patients that are not as seriously ill and give physicians more time to see critically ill patients, he says.
At Barrington Family Practice, part of Frisbie Memorial Hospital in Rochester, PA Shawn Roussin says the volume of patients coming through the door this past winter was significantly increased, adding it was driven by a bad flu season. Barrington Family has three full-time PAs and three physicians. Dr. Daniel Mazza, who also works at the Barrington practice, says having a mix of providers allows the practice to serve more patients.
While recruiting physicians is becoming increasingly difficult, Kevin Donovan, vice president for physician services for Elliot Health System in Manchester, says Elliot feels patient access to doctors is critical. The hospital employs about a dozen each of PAs and NPs, as well as about 100 doctors. We focus on the patient/physician relationship first and then look to augment with physician assistants and other [providers], he says. It's a good trend as long as it's managed appropriately.
While nurse practitioners and physician assistants alone won't resolve the shortage of primary care providers, they are a crucial part of the solution. It comes down to providing access to primary care in a number of ways, says Gaudreau of Portsmouth Regional Hospital. And Greg Bennett, president of the American Academy of Physician Assistants, says their ranks will keep growing. I expect [growth] will continue through at least 2025 as Baby Boomers get older and the number of people not in the workforce needing health care rises, Bennett says.
What is a Nurse Practitioner (NP)?
Nurse practitioners are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute health care services._Nurse practitioners complete a master's degree program. In total, they receive seven to eight years of post-secondary education before becoming a nurse practitioner. They take health histories and provide complete physical examinations; diagnose and treat many common acute and chronic problems; interpret laboratory results and x-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed.
Nurse practitioners are authorized to practice across the nation and have prescriptive privileges, of varying degrees, in 49 states, including NH. The Granite State is one of 23 states that allow nurse practitioners to operate independently of physicians and to operate their
own practices.
Source: American College of Nurse Practitioners
What is a Physician Assistant (PA)?
Physician assistants are health care professionals licensed to practice medicine with physician supervision. PAs attend graduate level courses accredited by the Accreditation Review Commission on Education for the Physician Assistant. The average PA program curriculum runs approximately 26 months. Upon graduation, physician assistants take a national certification examination developed by the National Commission on Certification of PAs in conjunction with the National Board of Medical Examiners. To maintain their national certification, PAs must log 100 hours of continuing medical education every two years and sit for a recertification every six years.
Physician assistants conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery and write prescriptions. Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. A PA's practice may also include education, research and administrative services.
Source: American Academy of Physician Assistants
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