On October 3, 2019 President Trump unveiled an Executive Order titled “Protecting and Improving Medicare for Our Nation’s Seniors.”

While we strongly endorse the goals of improving access to medical care to Medicare patients while removing regulatory barriers, Physicians for Patient Protection, a grassroots organization representing over 10,000 physicians, is deeply concerned about policies proposed in Section 5 of the executive order.

This section, titled: “Enabling Providers to Spend More Time with Patients,” proposes legislation that will increase the utilization of nurse practitioners and physician assistants in the care of Medicare patients, and will have an adverse effect on patient access to physician-led care.

Section 5 (a) proposes regulation that will:

“…eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements of the Medicare program that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their profession.”

Such regulation is dangerous because it would potentially override medical staff bylaws and policies designed to provide proper oversight of clinicians with less training than a physician.  The order also fails to define “practicing at the top of their profession,” which increases the risk of clinicians switching specialties without performing the necessary additional training.

Physicians are required to complete a minimum of 15,000 supervised clinical training hours before they are permitted to practice medicine independently.  Nurse practitioners are licensed to practice their professions with just 3% of the training of a physician (500 hours for NPs vs 15000 hours for physicians, minimum).  Physician assistants are licensed to practice their professions with about 13% of the training hours of a physician.

Non-physicians often claim that studies show that they can provide the “same” level of care as a physician despite a fraction of the training.  However, they neglect to mention that all the studies validating the use of non-physicians have included physician supervision and utilized physician-developed protocols to treat specific conditions and problems.

There are absolutely no validated scientific studies that have shown the safety and efficacy of non-physicians practicing independently of physician supervision.

Section 5(c) calls for pay parity between non-physicians and physicians:

“ (c)  conducting a comprehensive review of regulatory policies that create disparities in reimbursement between physicians and non-physician practitioners and proposing a regulation that would, to the extent allowed by law, ensure that items and services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”

Currently, Medicare pays nurse practitioners and physician assistants 85% of the physician rate when billed under the non-physician’s provider number.  Advocates of Section 5 argue that paying non-physicians and physicians the same allows free market forces to “let the market decide.”  In theory, patients would have the freedom to select the health care provider that they prefer—whether a nurse practitioner, physician assistant, or physician.

But in today’s profit-driven health care system, now overrun by private equity firms, the reality will likely be far different.  If Medicare pays the same rate for physicians and non-physicians, corporations will be incentivized to hire more nurse practitioners and physician assistants, especially if supervision is no longer required.

Patients visiting hospitals and large health centers will lose the choice of seeing a physician for their care.

This legislation would also have a negative impact on primary care physician residency training programs, decreasing the ever-dwindling supply of primary care doctors.

Physicians for Patient Protection proposes the following solutions to enhancing Medicare while protecting patients.

  1. While physicians, nurse practitioners, and physician assistants are members of the health care team, they provide very different services unique to their discipline. As such, we propose that each profession be designated their own specific billing codes to represent the various professions.  This change will allow more accurate studies to be performed to assess the quality and cost of care, and payment may be established commensurate with the value provided.
  2. Currently, nurse practitioners and physician assistants are not held to the same medicolegal standards as physicians in malpractice suits—a physician may not testify against a non-physician regarding standard of care in a court of law. If non-physicians are to be treated legislatively as “equal” to physicians, then these clinicians should be held to the same standard of care in a malpractice suit.
  3. Increase the ability of physicians to treat Medicare patients by establishing health savings accounts that can be used for Direct Primary Care or direct care from specialists. President Trump’s Executive Order seeks to expand health savings accounts for Medicare Advantage Plans.  In addition, patients should be permitted and encouraged to use health savings accounts to directly pay their physician.
  4. Repeal the section of the Affordable Care Act that bans physicians who accept Medicare dollars from owning and operating their own hospitals. Studies show that physician-owned hospitals provide better quality and value.
  5. Increase physician residency training programs and incentivize students to choose primary care as a specialty. The Affordable Care Act increased funding to nurse practitioner and physician assistant training programs, which have exploded over the last ten years, while doing little to expand the pipeline of physicians.  Primary care physician residency programs must be properly funded as well, since studies show that continuity of care with the same physician decreases mortality.  On the other end of the spectrum, studies show that lower quality of care by improperly trained clinicians is worse than no care.  To improve health care in America, we must invest in medical education and provide physician access to all patients.

Author:  Rebekah Bernard MD, President of Physicians for Patient Protection