Nurse Practicioners

After playing a round of golf with my buddies over the weekend, I got the chance to celebrate a rare hole-in-one (unfortunately, not mine). According to tradition, the person who hit the hole-in-one buys everyone in the bar a drink (alcoholic or nonalcoholic), so we all had a mid-afternoon celebration on “Bob.”

One of the golfers in the group, Tom Salines, happens to be a “nurse practitioner” (NP) and out of the blue, guys began to ask him questions related to primary medical care.

As someone whose business is absorbed with the many facets of health care planning, I am always interested in learning as much as I can about the field, so we all spent a considerable amount of time discussing the expanded role of nurse practitioners in health care. Since he enlightened us on several topics, I thought it would be good idea to record much of the session. The following is a list of our questions and Tom’s answers, which helped us to better understand the role, importance, and future of nurse practitioners.

What is the difference between a nurse practitioner and a nurse?
Nurse practitioners have a master’s degree, learn advanced practices, and receive additional training.

How long have you been a nurse practitioner?
Since 1998.

How many physicians in your practice?
There are two physicians, and one is an endocrinologist.

Do you work for each physician or one in particular?
I work for one of the physicians in the practice.

How do you distinguish what ailments should be addressed by you or the physician you work for?
There really aren’t any significant differences in the service we provide in our practice. Nurse practitioners have the privilege and authority to deliver primary medical care to patients. We can diagnose, prescribe medications, perform office procedures and diagnostic tests, and have our own panel of primary-care patients.

What do you mean by, “your own panel of patients”?
Many insurance plans allow me to care for my own primary care patients. Any of you could potentially have me as a primary care provider.

How many patients do you have?
That question needs to be clarified. Do you mean total – in my panel?

Our combined practice has approximately 5,000 patients.

I am sure that you have an extremely busy practice. Can being overworked affect your performance or the quality of care you provide?
Primary care doctors and nurse practitioners are on the front line, which ultimately determines the quality of care a person receives as they enter the system. Therefore, I always schedule my daily workload to ensure that I deliver the highest quality of care at all times.

If I’m going to the doctor, are my copays and coverage the same for a nurse practitioner and a physician?
Well, that can depend on the insurance carrier, but usually yes, your payment is the same.

Could my copay vary?
It could, but normally your copay is the same to see a physician or nurse practitioner.

So if my cost is the same whether I see a doctor or nurse practitioner, why wouldn’t I request to see a physician, who has more training and experience?
I think it depends on the patient and what he or she is accustomed to. Looking into the future, nurse practitioners are going to be held as accountable as physicians and will be viewed as primary providers by the public.

Are there areas in your practice in which you actually have more experience than the physician?
No. I think nurse practitioners are capable of providing an equivalent level of primary care services. Some people feel more comfortable seeing their physician, and that’s fine.

It sounds like a nurse practitioner is fairly close to being a doctor. Is that correct? Is your education the same as a doctor’s?
It’s similar, but not the same. I have a master’s degree. Physicians have a doctorate and more training than nurse practitioners, but in the eyes of the Commonwealth of Massachusetts, we’re comparable when it comes to providing primary care services.

So what’s the difference between a nurse practitioner and a physician’s assistant?
Nurse practitioners perform many of the same tasks and work closely with physicians’ assistants, but according to most state and federal regulations, nurse practitioners are more autonomous and can have their own panel of patients. At this time, physician assistants cannot have their own panel of patients.

So, do physician assistants have any real “authority”?
Of course they do. For examples, they can write prescriptions. It comes down to a difference in medical models: caring vs curing. Physician assistants tend to focus on a curing approach, while nurse practitioners lean toward a caring model.

Is that consistent from one state to another or does it vary by state?
Some states have different regulations, but for the most part, it’s consistent.

Can you talk for a bit about walk-in clinics?
Walk-in clinics are good to have for minor illnesses like sore throats, coughs, and things of that nature. It certainly beats going to an emergency room and getting hit with a high copay. I would still prefer for people to see their own primary care provider, but for those who do not have a primary care provider or have limited finances, it might be little less expensive to visit a walk-in clinic rather than an emergency room.

Whether you are a nurse practitioner or a physician, what is your biggest issue with insurers?
The reimbursement process. For a number of reasons, providers don’t get compensated for all the procedures or the services provided to a patient during an appointment. Insurance company payment systems are based on pre-established levels of care, which can be difficult to apply to specific cases. For example, there’s some conflict over authorizations and prescriptions – like name-brand vs generic medications. To be fair, insurers are attempting to manage rising health care expenses while working with providers in an effort to maintain the quality of care we have all become accustomed to.

Do you believe that hospitals today – both teaching and community hospitals – should publish pricing for various types of procedures, so that we, as consumers, can evaluate our options?
Yes, I do. I think there should be full disclosure.

So why is it not done?
That’s a pretty open-ended question, and I don’t know the answer. I do believe, however, that hospitals have a legal obligation to disclose pricing for procedures. The problem is there is no “menu,” but patients should have access to a price list.

What would you like to see changed in the health care industry that may actually improve the quality of care and potentially lower costs.
Appropriate care doesn’t always fall into an established payment system. Insurers and providers need to work closely together to design a more flexible system that allows caregivers to provide high-quality service while ensuring that medical practices receives the appropriate level of compensation for services rendered.

What is the biggest expense you have in your practice?
Vaccines. If we do not bill or get reimbursed for a vaccine, such a shingles or pneumonia, it can get very expensive.

What is the most important thing Americans need to know in order to be a “good patient”?
Be accountable for your own health. If we suggest you get screening tests or do blood work for medications that you take, please follow through, be responsible, and listen to our advice.

I decided to publish this interview because nurse practitioners have become a critical component of our evolving medical system. According to the Kaiser Family Foundation, there are over 174,826 NPs and 91,921 Physician Assistants practicing today, as compared to 208,807 primary care physicians. Research has revealed that nurse practitioners provide equitable medical care and may actually lower health care costs, so it is likely that their role will continue to expand in health care settings across the country.

Let’s face it, there is a growing shortage of primary care physicians in the United States, and it appears that nurse practitioners and physician assistants will continue to fill this critical void in the delivery of primary care. Also, with health care likely to rise by 6% annually for the foreseeable future, any adjustment to practice that portends to lower costs is going to be considered.

While this transition to nurse practitioners may be difficult for some Americans who are comfortable with their physicians, the habit associated with our traditional routine of going to the doctor may soon be replaced because of increased demand for medical services from an aging population that places considerable strain on an already fragile system.

This dilemma is not going unnoticed by other industries – including financial services – which are continuing to modify practices to include health care costs in the planning process. Unfortunately, those who believe that Medicare, which just celebrated its 50th birthday, is going to be the magic panacea for retirement health care costs, will be in for an unfortunate surprise: quality health care in the future is going to be more expensive for everybody. (If you would like more information on this topic, please go to

My recommendation: do not dismiss a nurse practitioner as a valued provider of medical care, and start putting some extra money away to prepare for unexpected health care costs.