Providing primary care for the poor: Nurse practitioners and physician assistants stand ready to meet the challenge, again

(Pittsburgh Post Gazette) A sentence in the article “Can Medicaid Solve Our Ills?” in the Sept. 9 Post-Gazette caught my eye. Quoting Dr. Alan Yeasted, reporter Bill Toland wrote, “There is somewhat of a shortage of PCPs (primary care physicians) and a bigger one looming in the future.” This will especially be true in Pennsylvania if the governor expands Medicaid coverage under the provisions of the Affordable Care Act.

I couldn’t help but remember similar concerns expressed in the 1960s when primary care physicians also were in short supply, a shortage sure to be exacerbated with the passage of Medicare and Medicaid.

What’s different, though, is the changing face of primary-care delivery, which now includes the extensive use of nurse practitioners and physician assistants. Indeed, it was the legislation that created Medicare and Medicaid in 1965 that spurred the development of these professions.

The prospect of providing access for the elderly poor to primary care, from which they had been excluded, mainly due to cost, raised thorny questions. How could we possibly care for so many who were so sick? For there was no doubt that the elderly poor, having gone without primary care for most of their lives, were sick and needed help.

The ’60s was a time of ferment in America, with civil rights, women’s rights, the antiwar movement and other struggles challenging long-accepted norms. One norm that changed was the role of nurses.

At the time, nurses, virtually all of them women, were educated in hospitals and largely worked in hospitals. Their functions diverged sharply from those of physicians, and many state nursing laws prohibited nurses from performing “acts of medical diagnosis.”

Fast forward to 2012 when we encounter nurse practitioners in retail clinics, physician offices, emergency departments, family planning programs and in many other settings.

This change took almost 50 years. The first programs to educate nurse practitioners and physician assistants were founded in 1965 by visionaries who saw that nurses could handle health promotion and disease prevention and that military corpsmen could build on their service-related experience to extend the reach of physicians. The University of Colorado hosted the first nurse practitioner program, which focused on the care of children. Duke University in North Carolina created the first physician assistant program.

The need for additional primary-care providers and the effectiveness of nurse practitioners in filling that role has resulted in a tremendous growth of nurse practitioners in Pennsylvania. According to the Pennsylvania Coalition of Nurse Practitioners, more than 7,000 currently practice in the commonwealth.

These nurses hold degrees at the master’s level. In the near future, nurse practitioners will be prepared at the doctoral level, earning Doctor of Nursing Practice degrees. This reflects the growing responsibility shouldered by nurse practitioners in providing primary care to a diverse population.

Furthermore, nurse practitioners are more likely to work in rural and remote areas than are other primary-care providers. When, in 1965, caring for the large influx of poor and sick strained the resources of organized health care delivery, the country responded by developing community health centers. Care provided in these centers is judged to be among the most cost-efficient provided in our health system. New models of care delivery, utilizing teams of physicians, nurse practitioners and other health care professionals, are needed as we face new challenges.

Almost 50 years after the first nurse practitioners graduated from the University of Colorado, their importance to the provision of primary care was recognized by the Institute of Medicine in its 2010 publication “The Future of Nursing: Leading Change, Advancing Health.” Nurse practitioners have been studied since their field was created, and their ability to deliver high-quality, cost-effective health care has been demonstrated repeatedly. They, and their physician assistant colleagues, stand ready to again help alleviate a looming shortage in primary care.