Non-Physician Clinicians in the Health Care Workforce

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Non-Physician Clinicians in the Health Care
Workforce

• William J. Pettit, D.O.Associate Dean for Rural
  HealthOklahoma State UniversityCenter for
  Health Sciences

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Pre-Lecture Quiz
Instructions Chose the best answer from the list
below for each of the following descriptions.

• Psychology
• Homeopath
• Podiatry
• Optometry
• Nurse Practitioner

1. Chiropractors
2. Naturopath
3. Physical Therapy
4. Pharmacist
5. Physician Assistant

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refer to themselves as doctors or physicians,
diagnose and treat patients whose health problems
are associated with bodys 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

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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 providedinclude 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

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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

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NPCs in the Health Care Workforce 1
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Background
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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

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Access to Care

• Tabers 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 NPCs considered lower cost alternative

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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

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Non-Physician Clinicians in the Health Care
Workforce 2
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AOA 2005

• Education
• Licensure
• Relationship to Physicians
• Prescriptive Authority
• Reimbursement
• Legislative Agenda

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Oklahoma Licensed NPCs

• 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)

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Oklahoma NON Licensed NPCs

• Acupuncture
• Naturopath
• Homeopath

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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

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Prescriptive Authority

• Full Only DO and MD
• Partial ARNP, PA, Optometrist
• None Chiropractic, Homeopath, Naturopaths

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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

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Non-Physicians in Healthcare Workforce 3
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Primary Care in Crisis

• National Data
• Graphs, tables and maps

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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, 2006.864-866
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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, 2006.861-864
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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, 2006.861-864
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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, 2006.861-864
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Primary Care in Crisis

• continued

• Oklahoma Data
• Graphs, tables and maps

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OSU College of Osteopathic Medicine Graduates
Entering a Primary Care Residency1977 - 2008
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Number of Patient Care Physicians in Oklahoma
Neighboring States Per 100,000 Population
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Number of Primary Care Physicians in Oklahoma
Neighboring States Per 100,000 Population
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Primary Care in Crisis

• continued

• OHCA Concept
• DO, MD, ARNP, PA (Sooner Care)

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Healthcare Urban vs. Rural
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Healthcare Urban vs. Rural
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Non-Physicians in Health Care Workforce 4
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2008 Concept of PCMH

• Primary care physicians play an integral role in
  coordinating a patients 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

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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

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OHCA January 2009

• PCMH DO, MD, ARNP, PA, FQHC, RHC, HIS
  Facilities
• Networks Hospital, Community Health Centers,
  Public Health Departments, Physicians, RHCs,
  FQHCs or other recognized safety net providers
  (OSU and OU)

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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

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NPCs in Health Care Workforce 5
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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 PAs and ARNPs could
  credential for hospital, there must be, by law, a
  relationship with a physician