Non-Physician Clinicians in the Health Care Workforce William J. Pettit, D.O. Associate Dean for Rural Health Oklahoma State University Center for Health Sciences

Pre-Lecture Quiz 1.Psychology 2.Homeopath 3.Podiatry 4.Optometry 5.Nurse Practitioner 6.Chiropractors 7.Naturopath 8.Physical Therapy 9.Pharmacist 10.Physician Assistant Instructions: Chose the best answer from the list below for each of the following descriptions.

“…refer to themselves as doctors … or physicians, diagnose and treat patients whose health problems are associated with body’s muscular, nervous, and skeletal systems, especially the spine. …more than 90% …consider themselves as primary care practitioners and believe that they should be, are, the ‘primary care portal of entry’ for health care for their patients.” 1.Psychology 2.Homeopath 3.Podiatry 4.Optometry 5.Nurse Practitioner 6.Chiropractors 7.Naturopath 8.Physical Therapy 9.Pharmacist 10.Physician Assistant

“…advanced academic and clinical experience, which enables him or her to diagnose and manage most common and many chronic illnesses, either independently or as part of a health care team. Services provided…include but are not limited to ordering, conducting, and interpreting appropriate diagnostic and laboratory test, prescription of pharmacological agents and treatments and therapies. The type of training and certification required is dictated by state licensure laws and therefore vary from state to state.” 1.Psychology 2.Homeopath 3.Podiatry 4.Optometry 5.Nurse Practitioner 6.Chiropractors 7.Naturopath 8.Physical Therapy 9.Pharmacist 10.Physician Assistant

“…holistic approach to medicine that takes a wider view of illness, causes of disease and how people express their diseases individually. … refer to themselves as physicians …use natural remedies to assist the body in its natural tendency to heal itself. … based on three principles: the law of similars, the principle of minimum dose and prescription for the individual. Some … regard mental, emotional, physical and even spiritual illnesses as interconnected, remedies are prescribed on an individual basis, not merely for his/her disease…” 1.Psychology 2.Homeopath 3.Podiatry 4.Optometry 5.Nurse Practitioner 6.Chiropractors 7.Naturopath 8.Physical Therapy 9.Pharmacist 10.Physician Assistant

NPC’s in the Health Care Workforce 1

Background

Definition of NPC ►Mid-level providers intended to work under the supervision of or in collaboration with a physician ►Others who work independently of physician in a certain medical area ►Lastly, those who practice as an independent alternative therapy

Access to Care ►Taber’s Medical Dictionary: “The right or ability of an individual to obtain medical and health care services” ►People without health care “access” for the notion of public health is best served by the broadest access to the healthcare workforce ►Efforts to provide health care by providers other than physicians ►In the face of rising health care costs consumers and employers are looking for cost saving options ●includes state and federal initiatives ●many NPC’s considered lower cost alternative

Scope of Practice ►Dependent on state law, therefore variable state to state what services can be provided ►Expansion of scope of practice by “legislation” not “education” ●Prescriptive, surgery, autonomy, are some of the issues

Non-Physician Clinicians in the Health Care Workforce 2

AOA – 2005 ►Education ►Licensure ►Relationship to Physicians ►Prescriptive Authority ►Reimbursement ►Legislative Agenda

Oklahoma Licensed NPC’s ►No Anesthesiology Assistants (legislation last year) (BA) ►Certified Registered Nurse Anesthetist (RN) ►Certified Registered Nurse Practitioner (RN) ►Physician Assistant (Prerequisite varies – usually BA) ►Optometrist (Prerequisites varies – usually BA) ►Pharmacist (Six year program to Pharm D) ►Psychologist (BA) ►Podiatrist (BA) ►Physical Therapist (Prerequisite varies – usually BA) ►Chiropractor (Prerequisite varies – usually BA)

Oklahoma NON Licensed NPC’s ►Acupuncture ►Naturopath ►Homeopath

Relationships to Physicians ►Supervision – You are bound to a physician in order to practice ●Physician Assistants ►Collaborative – Pharmacist and ARNP ►Independent – ARNP, Podiatrist, Chiropractor, Optometrist

Prescriptive Authority ►Full – Only DO and MD ►Partial – ARNP, PA, Optometrist ►None – Chiropractic, Homeopath, Naturopaths

Reimbursement ►Medicaid – Primary care givers are DO, MD, PA, ARNP ►Medicare – DO, MD, Psychologist, Podiatrist, PA, ARNP, ARNA, Optometrist, Chiropractor, Physical Therapist ►Private – Variable ►Compared to DO and MD some are on a lower scale; Psychology, for example, compared to Psychiatrist in Medicaid

Non-Physicians in Healthcare Workforce 3

Primary Care in Crisis ►National Data ●Graphs, tables and maps

Primary Cary Supply Figure 2. Percent Change between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties. Data are from the National Resident Matching Program. From: Woo: N Engl J Med, Volume 355(9).August 31,

Figure 1. Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program. From: Bodenheimer: N Engl J Med, Volume 355(9).August 31,

Figure 2. Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists. For 2001, the data reflect the career plans for all third-year internal medicine residents, including categorical, primary care, medicine- pediatrics, and other tracks. Data for all other years reflect the career plans of third-year residents enrolled in categorical and primary care internal medicine programs. Data for 1998 through 2003 are from Garibaldi et al. [6] Data for 2004 and 2005 are from Carol Popkave, American College of Physicians. NA denotes not applicable. From: Bodenheimer: N Engl J Med, Volume 355(9).August 31, [6]

Figure 2. Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists. For 2001, the data reflect the career plans for all third-year internal medicine residents, including categorical, primary care, medicine- pediatrics, and other tracks. Data for all other years reflect the career plans of third-year residents enrolled in categorical and primary care internal medicine programs. Data for 1998 through 2003 are from Garibaldi et al. [6] Data for 2004 and 2005 are from Carol Popkave, American College of Physicians. NA denotes not applicable. From: Bodenheimer: N Engl J Med, Volume 355(9).August 31, [6]

Primary Care in Crisis ►Oklahoma Data ●Graphs, tables and maps continued

OSU College of Osteopathic Medicine Graduates Entering a Primary Care Residency

Number of Patient Care Physicians in Oklahoma & Neighboring States Per 100,000 Population

Number of Primary Care Physicians in Oklahoma & Neighboring States Per 100,000 Population

Primary Care in Crisis ►OHCA Concept ●DO, MD, ARNP, PA (Sooner Care) continued

Healthcare: Urban vs. Rural

Non-Physicians in Health Care Workforce 4

2008 Concept of PCMH ►“Primary care physicians play an integral role in coordinating a patient’s overall care.” ►AOA, AAFP, AAP, and ACP 2007 Seven Joint Principles: ●Personal Physician ●Physician Directed Medical Practice ●Whole-Person Orientation ●Coordinated and/or Integrated Care ●Quality and Safety ●Enhanced Access ●Better Payment Model

History ►North Carolina Model led to $225 million dollar savings in health care costs ►CMS (Centers for Medicaid and Medicare Services) will do demonstration projects in 2009

OHCA January 2009 ►PCMH – DO, MD, ARNP, PA, FQHC, RHC, HIS Facilities ►Networks – Hospital, Community Health Centers, Public Health Departments, Physicians, RHC’s, FQHC’s or other recognized safety net providers (OSU and OU)

OSU CHS and the Center for Rural Health ►Rural Residency Programs – Tahlequah, Enid and Durant; Lawton in non-primary care, EM ►OSU Physician Clinics – Enid, Country Club Gardens ►Quad System of Education Approach ►Telemedicine for Specialty Care ►OSU MC ►Maps and Pictures

NPC’s in Health Care Workforce 5

Discussion ►Health Promotion and Disease Prevention ►Quality and Safety ►Electronic Health Records E-Prescribing ►Changing the Primary Care Reimbursement Levels ►In Oklahoma the only “full service” providers are the MD and DO; although PA’s and ARNP’s could credential for hospital, there must be, by law, a relationship with a physician