AMA to Fund Studies Comparing Care From Physicians vs NPs, PAs

Concerned that unsupervised nurse practitioners (NPs) and physician assistants (PAs) provide patient care that is not as good or safe as that provided by physicians, the American Medical Association (AMA) House of Delegates voted Tuesday to fund independent studies that compare outcomes.

“Legislators continue to hear claims from NP and PA advocacy groups that studies say they are just as good or better than physicians,” said Rebekah Bernard, MD, of Fort Myers, Florida.

“We know these studies are referring to patients that are being seen for low conditions, for simple problems and always involve physician oversight,” added Bernard, who was representing the Florida delegation, which introduced the proposal with delegations from Texas and Oklahoma. “But legislators are not hearing these caveats. We need rigorous, independent data on the safety, efficacy, and cost of unsupervised NPs and PAs, and we need it urgently.”

Speakers said state regulatory agencies need data based on science in order to set scope-of-practice rules.

Several delegates said they’ve been referred to see patients who were previously inappropriately treated by mid-level providers.

Michael Lubrano, MD, of Massachusetts, speaking for the American Academy of Pain Medicine, cited Medicare data indicating “an explosion of nurse practitioners providing unsupervised advanced chronic pain injection therapies with unclear oversight and accreditation processes.”

An essential pain procedure code, he said, was flagged for overutilization, but the claims did not come from physician proceduralists. “This is a wake-up call,” he noted. “The nursing organizations are not going to fund legitimate comparative studies because they know what the outcomes will be.”

The resolution, which prompted a 35-minute debate, received pushback from some delegates who did not think state lawmakers and licensing agencies would believe an AMA-funded study that concluded that physicians provide better care than advanced practice nurses or physician assistants.

“I think that it’s a clear conflict of interest when we are specifically looking at studies to say that our care is superior to others,” said Brandi Ring, MD, of Keene, New Hampshire, speaking for the American College of Obstetricians and Gynecologists. “I think that’s true … but who else is going to believe that that is true? The nurse practitioner agencies, the physician assistant agencies will not, and our legislators are swayed by their testimony significantly.”

Douglas DeLong, MD, of Cooperstown, New York, pointed out that if “we looked at something where Big Pharma has funded drug studies, that implies an implicit bias. I think this could come back to bite us.”

Delegates clarified that the intent is that the AMA will find legitimate researchers who will conduct the studies honestly and objectively.

The original resolution was that the AMA would merely advocate for and support such studies. But after vigorous discussion, it was amended to specify that the AMA will “fund independent, academically rigorous studies performing comparative effectiveness analyses of patient outcomes between autonomous non-physician practitioners and physician-led (MD/DO or foreign equivalent) care models.”

The studies will look at patient safety, care quality, utilization, access, cost, and health outcomes, with a goal of publication in a peer-reviewed scientific journal.

Luke Selby, MD, of Westwood, Kansas, said the hope was that the AMA would solicit proposals from academic researchers, “and ask them to look at the question, and we’ll get back what we get back, and it will be editorially independent.”