Decreased quality, higher cost

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The landmark study “Targeting Value-based Care with Physician-led Care Teams” published in the Journal of the Mississippi State Medical Association (2022) showed that having an NP or PA-led primary care was associated with:

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• Decreased quality - Physicians performed better than NPs/PAs in 9 out of 10 quality measures

• Increased cost - totaling $10.3 M per year for the accountable care organization 

• Increased ER visits, even though NP/PA patients were younger and healthier. Further, NP/PA patients were more likely to go to the ER than patients without any PCP at all

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These results led to a policy change: Hattiesburg Clinic no longer allows NP/PAs to act in a primary care role - all patients are seen by a primary physician, with NPs/PAs working under physician direction in a truly physician-led team

 

More tests, more medications, more referrals, more biopsies

 

While physicians are being urged to “choose wisely," research raises concerns about nonphysician practitioner overuse of health care resources, with studies showing that NPs/PAs:

 

• Order more tests than physicians:

  • More tests overall (Flynn, 1974)

  • More x-ray imaging (Goldberg, 1981; Hughes, 2015; Rosenberg, 2015; Mizrahi, 2018)​​​​​​

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• Prescribe more medications in general than physicians (​Muench, 2017​​

  • Prescribe more opioids (Ellenbogen, 2020; Lozada, 2020)

  • Prescribe more psychotropic drugs to children (Yang, 2018)​

  • Prescribe more unnecessary antibiotics (Roumie, 2005; Schmidt, 2017)

  • More likely to prescribe steroids for upper respiratory infections (Dvorin, 2018)

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• Refer patients more frequently (Yong-Fang, 2015) and place lower quality referrals than physicians (Lohr, 2013)

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• Perform significantly more biopsies than physicians to diagnose skin cancer in patients < 65 years (Nault, 2015) and fail to diagnose melanoma-in-situ more often than physicians

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• Less likely to intensify medication regimens when needed (Morrison, 2012)

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Are more expensive

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• Do not lower staffing costs (Hollinghurst, 2006)

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CRNA-only care higher mortality rate

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Lower 30 day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care (Silber,​ 2000)

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