Recent increases in the number of Advance Practice Providers (APPs) have accelerated a trend that isn’t likely to end anytime soon—a transition to a patient care model that is less dependent on physicians.
This change is occurring not just in the US, but in a variety of jurisdictions around the world. These APPs, who operate in both primary care and specialty care, as well as in dentistry, pharmacy, and more, occupy a variety of roles that are stretching to provide needed care for aging and sick populations.
At the same time, their scope of practice is increasing as the demand for healthcare services outstrips the supply. In play is the increasing shortage of physicians and nurses in the US, Canada, Europe, Australia, South Africa, and beyond. APPs are picking up the slack, playing an increasingly critical role in the developed and developing worlds’ healthcare systems.
These systems are under an increasing amount of financial stress in the wake of the COVID-19 pandemic. As costs are rising, revenue is falling, creating a squeeze in healthcare operating margins.
The lower financial cost of employing APPs makes them an attractive employment target for healthcare systems. The rise of retail clinics sponsored by organizations such as CVS and Amazon creates a dynamic in which patients with simpler, easier to treat needs are turning to easy-to-access care, leaving health systems to deal with the patients who possess the most intense level of needs.
What’s less clear is how that will affect medical professional liability (MPL) risk management going forward. Recent evidence reveals that the increase in APPs to date has not led to a resultant increase in MPL claims. However, issues around supervision, practice scope, and the rising level of care required for the sickest patients create questions as to how this will play out going forward.
“When you put these trends together—staffing shortages, an aging provider population, an aging patient population with more intense needs, and the financial constraints we are operating under, it’s clear that we will become more and more reliant on APPs to provide care to the patients in our hospitals,” said Larry Smith, vice president for Risk Management at MedStar, a regional health system. “And everyone who is licensed is going to be asked to work to the top of their license—we’re going to ask people to stretch. If staffing wasn’t an issue, maybe we could use APPs for relatively low risk activities. But we don’t.”
This article will explore the evolving role of APPs in modern healthcare systems. You’ll gain awareness of how APPs work within the system, the factors driving their increasing presence in that system, and the potential risks that come with this emergence.
THE UNIVERSE OF APPS
In the US, there are several types of recognized APPs—nurse practitioners (NPs), physician assistants or associates (PAs), certified nurse midwives (CNWs), and certified nurse anesthetists (CNAs). The most common are NPs and PAs, which made up nearly a quarter of all clinicians practicing in the US in 2021.1 That group also includes physicians.
What’s remarkable is that between 2012 and 2021, the number of physician assistants and nurse practitioners increased by 94%.2 Not only that, but numbers are projected to continue to rise more rapidly than the pool of physicians by 2029 to the point where they will make up more than 30% of the provider population.3
The pool of APPs is also growing in the UK, which includes a number of roles within the nursing, pharmacy, paramedic, dental, and occupational therapy professions. The UK’s National Health Service (NHS) defines APPs as “healthcare professionals educated to master’s level and have developed the skills and knowledge to allow them to take on expanded roles and scope of practice caring for patients.”4
Nurse practitioners practice in Australia, Canada, Ireland, the Netherlands, Finland, and New Zealand.5 Clinical nurse specialists and physician assistants also practice in Canada. Additionally, physician assistants practice in the Netherlands and South Africa.6 Midwives practice in Australia, South Africa, throughout the European Union, and in many other countries around the world.
With a shortage of physicians in many developed countries, APPs are increasingly stepping into an expanded scope of practice in a variety of settings.
SCOPE OF PRACTICE EVOLVES
In the US, APP scope of practice is controlled by state legislators and healthcare regulators. That leads to a patchwork of practice scope around the country. While scope of practice may be more nationally oriented in other countries around the world, there is still considerable variance in what APPs are permitted to do.
As the number of APPs increases in the US, their scope of practice has also steadily increased across the country. “NPs now have full autonomy in more than half of the 50 states and supervision requirements for PAs are rapidly changing,” according to a report from Candello, the technology affiliate of CRICO.
Specifically, in the US, NPs and PAs have the following education, licensing, and practice scopes:
- NPs: On a national level, NPs are advanced practice registered nurses who obtain additional education at the master’s, post-master’s, or doctoral level and obtain national board certification. NPs practice autonomously and in coordination with other healthcare professionals.7
- PAs: They must graduate from an accredited PA program, pass the National Commission on Certification of Physician Assistants’ Physician Assistant National Certifying Examination, and obtain state licensure.8 The scope of practice for PAs, in most states in the US, is made at the individual practice level rather than a medical board or regulatory agency.9 Most PAs can perform tasks delegated by physicians that occur within the physician scope of practice.10
APPs, like physicians, are increasingly specializing both in the US and in overseas jurisdictions. “There don’t seem to be as many generalists anymore,” said Graham Billingham, MD, chief medical officer at MedPro Group. “Sub-specialization is alive and well within the APP community.”
PROVIDER SHORTAGES
In the wake of the COVID-19 pandemic, provider shortages have become more acute in both the developed and developing world. In the US, researchers estimate that the physician shortage will escalate to at least 30,000 or to as many as 100,000 doctors by 2034.11 For nurses, more than 100,000 nurses left the profession during the COVID-19 pandemic.12 The profession is aging and training programs are not projected to feed enough new nurses into the system to meet the growing need. Globally, the World Health Organization estimates a shortage of 4.3 million doctors, nurses, and other healthcare professionals.13
An aging US population highlights the need for more, rather than fewer, healthcare providers. By 2023, the number of Medicare-eligible US residents—those 65 and over—will increase to 69.7 million, nearly double the number in 2000.14 “Demographics—specifically population growth and aging—continue to be the primary driver of increasing [physician] demand from 2019 to 2034,” according to a report from the Association of American Medical Colleges.15 At the same time, “a large portion of the physician workforce is nearing traditional retirement age, and supply projections are sensitive to workforce decisions of older physicians,” the report continues. “More than two of five currently active physicians will be 65 or older within the next decade.”
“There is no question APPs are here to stay,” said Smith. “The reality is that given the shortages we have currently within nursing and the aging and retiring physician workforce, coupled with the volume of patients and the complexity of their care, it is only going to be more and more difficult to find the people we need to take care of our patients.”
With physician shortages across the globe, patient access is another reason behind the increase in the number of APPs. “Patients are smart and if they don’t want to wait six hours or more in an emergency room, they can go into a retail clinic and see someone in 15 minutes for $70,” said Billingham. “More and more, patients want better information, faster service, and increased access—hence the rise in wearable healthcare technology, telehealth, and APPs.”
“There are a couple of reasons that we’re seeing the trends of APPs increase in the overall workforce,” said Julie Higden, senior program director, patient safety, at CRICO. “We’re seeing the need for PAs and NPs to work in healthcare for patients who need primary care providers. There’s also increasing utilization of PAs and NPs in urgent care and emergency departments.”
Going forward, patients are more and more likely to encounter APPs as they seek care. And as that care gets more complex, particularly within hospitals and healthcare systems, the question arises as to the degree to which patients will accept care from an APP rather than a doctor, said Smith. “As we continue giving more significant responsibility to APPs will the public be in agreement with us that the APP is the right person to provide care in a particular situation to that patient?” he continued.
SUPERVISION ISSUES
As APP professions expand and the supply of physicians shrinks, discord can arise between types of providers and their ideas on what supervision is required and exactly what that supervision should involve. Professional turf wars are breaking out in a variety of jurisdictions around the proper role of different types of APPs and potential risks involved in deploying more APPs to handle some tasks that were previously handled by physicians.
In the UK, for example, there is quite a bit of dissension about scope of practice and supervision, according to Matt Lee, MD, chief executive officer of the Medical Defence Union. “In a number of cases, the perception is that they’ve been brought in to fill staffing gaps and are not always appropriately deployed,” he said.
“And quite often there are questions on the ground as to whose responsibility it is to supervise these roles to the point to which the medical profession in the UK is starting to push back against further use or extension of these roles,” he continued. “We’ve had grass-roots doctor members of various Royal Colleges, including the College of Anaesthetists and now the College of Physicians, which hosts the Faculty of Physician Associates, pushing these professional bodies to intervene on behalf of the profession on safety and other grounds.” 16,17
A British Medical Association survey revealed that more than half of doctors surveyed report that PAs increase rather than decrease their workload.18 In addition, 87% believe that PAs or Anaesthesia Associates cause more risk due to the way they are employed by the NHS.19 Several organized groups of UK physicians caution against scope creep in APP professional duties and are concerned about the implications of growth in APPs.20
An issue in the UK and US is whether physicians are or will be asked to supervise an increasing number of APPs and sign off on patient care without potentially seeing the patients themselves. Ultimately, doctors wonder, Lee said, whether they will be expected to take responsibility for diagnoses and treatment decisions made by APPs and what will happen if something goes wrong. Billingham noted that this is a concern for some physicians in the US as well.
“What we do see here in the Medical Defence Union are quite a lot of member questions asking what is their responsibility for the APPs who may be under their supervision—either formally or informally,” said Lee. “We’re seeing as many inquiries from our physician members as to their responsibilities working alongside PAs as we are from the PAs themselves as to what they can do, what the scope of their practice should be, and what is reasonable for them to be able to do.”
In the US, the American Medical Association opposes practice expansion by APPs and other healthcare providers, including pharmacists, on the grounds that patients deserve care led by physicians and that such expansion “threatens patient safety.”21 On the other hand, NP and PA associations are actively lobbying for, and in some cases securing, state legislative approval for increases in scope of work and, for PAs, more ability to practice independently.22
“The COVID-19 pandemic was a catalyst for some of the practice authority changes we’ve seen across the country,” said Higden. “Within Massachusetts, for example, nurse practitioners have recently been granted full-practice authority, which means that after two years in practice, they can practice independently. Nurse practitioners tend to have more of a collaborative relationship with physicians, which is operationalized differently in individual institutions, whereas physician assistants still have what’s considered a supervisory relationship.”
COST CONSTRAINTS DRIVE APP RISE
Hospitals and health systems are under increasing financial pressure, as operating margins have either compressed or disappeared in the years since the COVID-19 pandemic began23 Major rating agencies, including Fitch, S&P, and Moody’s, report declining health system financial health, resulting in far more credit downgrades than upgrades. Overall hospital expenses increased by 17.5%—including labor costs, supplies, and pharmaceuticals—far outweighing Medicare reimbursement, which only increased 7.5% during the same period24
Financial pressures are causing all health systems to find more and more ways to rein in costs while maintaining a high quality of care. “The rise of retail clinics is syphoning off patients who don’t require an intensive level of care, leaving hospitals with the sickest of the sick,” said Smith. “That means the intensity of care in the inpatient experience is going to get greater and greater, requiring more and more resources. The retail giants with these clinics don’t want anything to do with this type of care we provide in the inpatient arena because there is no operating margin at all—none, zero.”
“We have to continue to identify ways in which we can provide high quality and safe care to allow us to cover the ever-increasing expenses,” he continued. “So, there is a huge economic component to this issue. The dependency on APPs is going to continue and grow even more over time driven by staffing shortages and financial necessities.”
RISK MANAGEMENT LANDSCAPE
A variety of studies, including a recent open and closed case analysis by Candello, revealed that the vast majority of MPL cases neither name nor involve PAs or NPs.25 Only 5% of MPL cases involve PAs, while 4% involve NPs. “I think some of the telling statistics are that despite the increasing numbers of APPs, CRICO hasn’t seen an increase in the proportion of MPL claims involving APPs, which is really interesting,” said David LeBlanc, an underwriter at CRICO. Both LeBlanc and Higden stated that the next five years of MPL data will be very telling as to whether APP risk does increase, especially as NPs gain more independent practice authority.
One data point from the CRICO report is that there are slightly higher rates of cases closing with indemnity payments when both an MD and an APP are named in a suit together. “I think that could be attributed to two things,” Higden said. “One is that APPs and MDs often collaborate on very acutely ill patients, which can lead to severe outcomes. Also, just by the nature of claims with multiple defendants, they will more frequently close with some sort of payment and/or the payment will be higher. It’s hard to draw exact conclusions, but these are some inferences.”
That being said, Billingham noted that there is pressure on frequency and severity of APP claims due to a number of factors. “First of all, just sheer volume—they are seeing many, many more patients because of demands for care,” he said. “Additionally, APPs’ scopes of practice have expanded, and they are seeing patients who have more complex medical conditions and needs. Previously, APPs were involved more in services like wound management, splinting, and casting fractures; now they are evaluating chest and abdominal pain, participating in resuscitation, and more.”
“Another factor relates to malpractice policies; in the past, doctors and APPs had shared limits policies. Now, we are seeing more separate limits for APPs, resulting in two policies instead of one,” Billingham said. “We are also having difficulty finding expert witnesses to defend claims. Finally, for the last 25 years, these providers were under the radar of the plaintiffs’ bar, and that isn’t true anymore.”
Risk mitigation factors for MPL claims against APPs—or APPs and doctors and/or health systems—are the same across the board. They include documentation, communication, patient assessments, closing the loop on test results, and similar strategies. Insurers, captives, and health systems all need to continue to educate providers, whether they are physicians, APPs, LPNs, or CNAs, to improve patient safety.
While the number of APPs is rising, as are concerns about potential risk management, this isn’t the case everywhere. In Australia, for example, MPL carriers such as MDA National don’t insure APPs. In addition, NPs, the main type of APP in Australia outside of certified nurse midwives, practice independently.
“I’m not sure of the events that would have to overlap between a doctor and a nurse practitioner for liability to result for the doctor, unless the doctor was coming in to save a particular situation or trying to help with a higher level of care that the nurse practitioner was providing,” said Ian Anderson, CEO at MDA National. “From an indemnity perspective, physician liability for an NP’s action would only occur based on their actions, not what’s been done prior to them getting involved.”
A FINAL WORD
The landscape of providers will continue to evolve over time. The priority for those who manage risk will be to balance those changes with the obligation to care for patients who are sick, aging, and with some of the most complex care needs in our society.
References
1 “A Sea Change in U.S. Care Delivery: An Analysis of Advanced Practice Provider and Physician Malpractice Risk,” CRICO, Dec. 18, 2023, https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2023/SPS-December-2023-Sea-Change
2 “A Sea Change in U.S. Care Delivery: An Analysis of Advanced Practice Provider and Physician Malpractice Risk,” CRICO, Dec. 18, 2023, https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2023/SPS-December-2023-Sea-Change
3 “A Sea Change in U.S. Care Delivery: An Analysis of Advanced Practice Provider and Physician Malpractice Risk,” CRICO, Dec. 18, 2023, https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2023/SPS-December-2023-Sea-Change
4 “What is Advanced Clinical Practice,” NHS England, https://www.hee.nhs.uk/our-work/advanced-clinical-practice/what-advanced-clinical-practice#
5 “Nurse Practitioners: The International Scene,” ThriveAP.com, https://provider.thriveap.com/blog/nurse-practitioners-international-scene
6 “PAs Working Abroad: Resources and Information,” American Academy of Physician Assistants, https://www.aapa.org/career-central/career-advancement-and-transitions/pas-working-abroad/#
7 “Scope of Practice for Nurse Practitioners,” American Association of Nurse Practitioners,” 2022, https://www.aanp.org/advocacy/advocacy-resource/position-statements/scope-of-practice-for-nurse-practitioners
8 “PA Scope of Practice,” American Association of Physician Assistants, September 2019, https://www.aapa.org/wp-content/uploads/2017/01/Issue-brief_Scope-of-Practice_0117-1.pdf
9 “PA Scope of Practice,” American Association of Physician Assistants, September 2019, https://www.aapa.org/wp-content/uploads/2017/01/Issue-brief_Scope-of-Practice_0117-1.pdf
10 “The Hidden Health Crisis: America’s Physician Shortage is Slowly Worsening,” Columbia Political Review, Feb. 12, 2024, http://www.cpreview.org/articles/2024/2/the-hidden-health-crisis-americas-physician-shortage-is-slowly-worsening
11 “Fact Sheet: Nursing Shortage,” American Association of Colleges of Nursing, October 2022, https://www.aacnnursing.org/Portals/0/PDFs/Fact-Sheets/Nursing-Shortage-Factsheet.pdf
12 “Physician Shortage,” News-Medical.net, Jan. 3, 2023, https://www.news-medical.net/health/Physician-Shortage.aspx
13 “The Baby Boomer Effect and Controlling Health Care Costs,” Sol Price School of Public Policy, University of Southern California, Nov.17, 2023, https://healthadministrationdegree.usc.edu/blog/the-babyboomer-effect-and-controlling-health-care-costs
14 “Physician Supply and Demand—A 15-Year Outlook: Key Findings,” American Association of Medical Colleges,” June 2021, https://www.aamc.org/media/54686/download?attachment#
15 “Anaesthesia associates: Royal college convenes extraordinary meeting after call from members,” TheBMJ.com, Sept. 11, 2023, https://www.bmj.com/content/382/bmj.p2076
16 “Faculty of Physician Associates’ Public Statement on the RCP Extraordinary General Meeting (EGM) Motions,” Faculty of Physician Associates, Royal College of Physicians, March 2024, https://www.fparcp.co.uk/about-fpa/news/faculty-of-physician-associates-public-statement-on-the-rcp-extraordinary-general-meeting-egm-motions
17 “Safe scope of practice for medical associate professions,” British Medical Association, March 28, 2024, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/medical-associate-professions-briefing/
18 “Safe scope of practice for medical associate professions,” British Medical Association, March 28, 2024, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/medical-associate-professions-briefing/
19 “Position Statement on Physician Associates in the UK,” Royal College of Physicians of Edinburgh, Jan. 16, 2024, https://www.rcpe.ac.uk/college/position-statement-physician-associates-uk
20 “AMA Successfully Fights Scope of Practice Expansions that Threaten Patient Safety,” American Medical Association, May 15, 2023, https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten
21 “Upcoming Changes to NP and PA Scope of Practice,” Hire.Vivian.com, Feb. 1, 2023, https://hire.vivian.com/blog/upcoming-changes-forapp-scope-of-practice
22 “Hospital Financial Health: A Rocky Recovery,” American Hospital Association, Sept. 27, https://www.aha.org/news/blog/2023-09-27-hospital-financial-health-rocky-recovery
23 “New AHA Report Finds Financial Challenges Mount for Hospitals and Health Systems Putting Access to Care at Risk,” American Hospital Association, April 20, 2023, https://www.aha.org/press-releases/2023-04-20-new-aha-report-finds-financial-challenges-mounthospitals-health-systems-putting-access-care-risk
24 “A Sea Change in U.S. Care Delivery: An Analysis of Advanced Practice Provider and Physician Malpractice Risk,” CRICO, Dec. 18, 2023, https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2023/SPS-December-2023-Sea-Change
25 “A Sea Change in U.S. Care Delivery: An Analysis of Advanced Practice Provider and Physician Malpractice Risk,” CRICO, Dec. 18, 2023, https://www.rmf.harvard.edu/News-and-Blog/Newsletter-Home/News/2023/SPS-December-2023-Sea-Change