In last week’s post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?
Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especiallyif it allows them to be seen sooner.
To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.
The researchers conducted a survey that focused on three different scenarios to judge patient preferences: a straight-up comparison of preference for physicians vs. NPs/PAs; a scenario where a patient could see a NP/PA today vs. a physician tomorrow for a minor ailment; and a scenario where a patient could see a NP/PA today vs. a physician in three days for a minor ailment. I’ve charted the results below.
In the first scenario, nearly half of respondents either preferred a NP/PA or had no preference (22.8% and 25.9%, respectively). This may be the most striking data point in the entire study; all things being equal, almost a quarter of all patients actually prefer to see a NP/PA over a physician. According to the authors, patients preferred NPs/PAs for reasons that highlight all three components of the Triple Aim: “… their lower cost…generally greater accessibility…and quality issues, including perceptions of more personalized and compassionate care, greater comfort levels in communicating …”
Of course, this still means that half of the respondents preferred being seen by a physician. When time became a distinguishing factor, though, a majority of patients preferred to immediately see a NP/PA – 66% in the third scenario. This could indicate that, at least for minor ailments, patients see NPs/PAs as providing a similar level of care, or it could indicate that patients are sufficiently worried about their condition that they want to be seen right away by someone with a clinical background.
Tellingly, patients who had been seen by a NP/PA in the past were more likely to prefer being seen by a NP/PA in the future; those whose last medical visit was with a NP/PA showed an even-stronger preference. For example, in the scenario where there was a one day gap, patients whose last medical care visit was with a NP/PA were an absolute 28% more likely to prefer being seen by a NP/PA than a physician (67.5% vs. 39.5%, respectively). When patients are used to seeing a NP/PA, they actively prefer seeing them again.
There are stark differences generationally, which the chart below shows. A plurality of Millennialsprefer being seen by a NP/PA over a physician (41% vs. 28%), while those 65+ vastly prefer physicians over NPs/PAs (77% vs. 6%). Our parents’ age group is in between, though a majority still prefer physicians.
This doesn’t seem all that surprising. The Boomers grew up in a completely different health care system ruled by physicians, while Millennials have grown up in an age where a physician is regarded as a (very important) member of the care team. Millennials are much more used to non-physician clinicians, a cultural shift which we’ve discussed before; a combination of being relatively health and interacting with the health care system in a different way is increasingly driving Millennials away from “typical” primary care providers and into retail clinics – staffed by NPs and PAs.
The authors note that, currently, about 30% of all primary care providers are NPs/PAs, a figure that is “… well below the 48.7 percent of our respondents who indicated in response to our theoretical scenario about selecting a new primary care provider that they would choose a physician assistant or nurse practitioner or had no preference.” In other words, the demand is there for increasing the scope of practice.
To be sure, this study doesn’t provide a complete view of the issue; we don’t know if patients are comfortable with being seen by a NP/PA without a physician backstop, for example. Also, the question asked in the study was about finding a new clinician; it didn’t ask what people preferred vs. their existing physician relationship. And we don’t know what patients would want in the moment, as they’re sick; it’s possible that even more patients would prefer to be seen by a NP/PA, especially if time was a factor.
But it’s the clearest indication yet that patients are ready for this shift in their health care consumption – if our legislatures will allow it. The authors make it clear (emphasis added):
Efforts to standardize scope of practice for physician assistants and nurse practitioners at a level that enables them to take full advantage of their training and skills have the potential to improve access, especially for underserved populations…as scope-of-practice battles continue to be waged and new reforms for care delivery and reimbursement roll out, our findings provide early evidence that health care consumers in the United States are open to the idea of seeing physician assistants and nurse practitioners in the future—and in many cases prefer it.