American College of Physicians, Physician-in-Chief Support Doctor-Led Care Teams

Nonphysician healthcare providers such as nurse practitioners should not be allowed to practice medicine independently, they say.

In a new position paper, the American College of Physicians (ACP) stresses the importance of physician-led care teams and makes several recommendations on team-based care.

Team-based care models have been linked to good patient health outcomes and better healthcare-professional collaboration. While physician associations such as the ACP promote physician-led, team-based care, groups including the American Association of Nurse Practitioners say that advanced practice providers such as nurse practitioners can function successfully in an independent and autonomous manner.

"Some healthcare professionals have sought to practice independent of the physician-led healthcare team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care," the ACP position paper says.

Although physician-led care teams generate positive results, the ACP position paper says these teams face barriers "including high implementation costs, insufficient financial incentives, and scope-of-practice changes that permit nonphysician healthcare professionals to practice outside of the physician-led team-based model."

To address these barriers, the ACP position paper makes several recommendations, including the following:

• Physicians should lead healthcare professionals functioning in a multidisciplinary team-based care model such as the Patient-Centered Medical Home (PCMH).
   
• Nurse practitioners, physician assistants, and other nonphysician healthcare professionals should not be allowed to practice medicine independently.
   
• Team-based care should be based on the best interests of the patient. Physicians should have sufficient time and financial resources to lead a healthcare team.
   
• Team-based care including physicians, advanced practice registered nurses, physician assistants, clinical pharmacists, and medical assistants is needed to address physician shortages.
   
• Licensing organizations should not consider the skills, training, clinical experience, and competencies of physicians, nurses, physician assistants, and other healthcare professionals as equivalent. State lawmakers should review their licensure laws to make sure they are consistent with this principle.
   
• Healthcare delivery and payment should be redesigned to promote physician-led, team-based care models such as the PCMH. Payment models should be designed to address healthcare disparities and meet the needs of individuals who are affected by social drivers of health.

Physician-in-Chief's perspective

Nonphysician healthcare providers such as nurse practitioners and physician assistants should not be allowed to practice medicine independently, says David Battinelli, MD, executive vice president and physician-in-chief of Northwell Health and dean of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

"Nonphysician healthcare professionals do not have the education, training, and experience that physicians have—it is not even close," he says. "Nonphysician healthcare professionals can do particular things particularly well, but that does not give someone the privilege to practice medicine independently."

Team-based care models such as the PCMH should be physician led, Battinelli says.

"The physician should be the ultimate leader of team-based care models," he says. "The physician possesses the education, training, experience, and specialty expertise to be the leader of a team. What people get concerned about is whether the physician has too much control. As with any good team, when team members can have specific roles that are in their wheelhouse in terms of their education, training, and experience as well as the top of their competency, then a team functions well. But it is ultimately the physician who should lead the team."

Care teams including advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, medical assistants, and other healthcare professionals can help ease physician shortages, Battinelli says.

"There are physician shortages and part of the problem is that physicians are asked to do a number of things that do not require their level of expertise and training," he says. "They could be doing other things and seeing more patients if they had other team members to help them carry out care. That can help address physician shortages."

Even if there were no physician shortages, there would still be a need to have team-based care, Battinelli says.

"Together, a team can provide the best care for patients," he says. "These teams should be physician led, but that does not mean that other team members do not have a particularly important competency-based skill set. Patients often need more than one doctor involved in their care. They need a team of providers led by a physician to take care of them. Depending on the care that is being provided, it may require nurse practitioners, physician assistants, pharmacologists, social workers, psychologists, psychiatrists, or other professionals. Everybody has a role to play."

Licensing bodies should recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurse practitioners, physician assistants, and other healthcare professionals are not equivalent or interchangeable, Battinelli says.

"Some parts of what professionals do are the same and interchangeable but not to the point of practicing medicine independently," he says. "You might have an endocrinologist who specializes in diabetes care, but that doctor can look at the entire patient. You may have a nurse practitioner or a physician assistant who has expertise in managing a patient's blood sugar. But these professionals are not interchangeable with the endocrinologist, who has four years of medical school training, three years of residency training, and three years of training in endocrinology. The nurse practitioner or the physician assistant cannot take care of the entire patient."

There needs to be a restructuring of reimbursement and how team-based care is valued, Battinelli says.

"For example, reimbursement for care such as general internal medicine, primary care, and family medicine is not sufficient; and as a result, you do not have professionals going into those areas," he says. "That has opened the door for people to say we have an access problem and a shortage of physicians, with a need for other allied health professions to fill some of that void. But that is not the proper fill. The proper fill is team-based care, where the patient is at the center of the effort and there is a multidisciplinary team led by a physician. … I would love to see somebody figure out how to pay for the program that is taking care of patients, so that there is enough resources and reimbursement spread out through the program to pay all the team members, including the physician who is leading the team."