The Impact of Nonphysician Clinicians

Abstract

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

A Systematic Review of the Cost-Effectiveness of Nurse Practitioners and Clinical Nurse Specialists: What Is the Quality of the Evidence?

“…Those working in alternative roles provide similar services to those for whom they are substituting, usually physicians [4]. Those working in complementary roles provide additional services that are intended to complement or extend existing services.…”

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

“…65 These calls reflect a growing international debate on the subject. 27,28,60 In a review of the international literature, Nash et al 66 conclude that 'access to basic dental care will not be available without the utilisation of dental therapists in the workforce', while Johnson 67 argues for a paradigm shift using DCPs to shift the culture 'from treatment to prevention, wellness and self-care'.…”

“…6 Skill mix is a term that is used to describe a model of care in which the whole of the clinical team is utilised in delivering service activity. 60 The use of skill mix in medicine is relatively developed, but dentistry has always appeared to lag behind. 6 Skill mix can be further subdivided into role substitution and role supplementation.…”

Moving Beyond the Medical Model to Enhance Primary Care

“…10,11 Studies note favorable health outcomes when care is delivered by PAs in comparison to physicians. [12][13][14] However, despite national educational standards, state regulation and mandates for physician oversight restrict PAs' scope of practice. Although PAs may be content to practice within the domain of medicine and a physiciandelegated scope of practice, APRNs are not.…”

“…18,46 Limited reimbursement and restrictive licensing for APRNs and PAs inhibit the full ability of these primary care providers to favorably enhance individual, family, community, and population health. A key question emerges: If APRNs and PAs provide high-quality care with equal or better outcomes when compared to physician providers, 7,14,17,18 why are they reimbursed at a lower level?…”