Physician-Led Care Matters — What the Data Shows

What Patients Expect

Patients value physician training, oversight of NPPs, and transparency about who is treating them.

The vast majority of patients prefer physician-led care.

Myths vs. Truths

Find out the truth compared to the common claims.

There are NO studies that support NP independent practice is safe or effective.

What the Research Says

Learn more about peer-reviewed studies on physician-led care.

Get the Facts!

What Patients Expect from Their Healthcare

Patients Have a Right to See a Physician

97%

of people felt that every patient should have the right to see a physician when they ask for one, instead of a NP or PA.

(PPP Public Survey)

96%

of people felt that the right to practice medicine should be earned by education, not legislation.

(PPP Public Survey)

Patients Have the Right to Informed Consent

51%

of people reported that they made an appointment to see a physician but when they arrived it was only an NP or PA that met with them.

(PPP Public Survey)

32%

of people have been (incorrectly) told by someone that an NP or PA is the same as a physician.

(PPP Public Survey)

20%

of people felt they should pay the same regardless of whether they saw a physician or an NP or PA.

(PPP Public Survey)

Patient Preferences On Their Medical Care

95%

of patients say it’s important for a physician to be involved in their diagnosis and treatment

(AMA Survey)

Only 8%

of people prefer to see an NP or PA

(PPP Public Survey)

71%

of people feel comfortable being treated by an NP or PA if their medical problem is simple or stable or if they know a physician is overseeing the care provided by the NP or PA.

(PPP Public Survey)

3 out of 4

would wait longer and pay more to be treated by a physician

(AMA Survey)

Importance of Physician-Led Care for Patient Safety

86%

of people felt that all healthcare should be led by physicians in order to protect patient safety.

(PPP Public Survey)

70%

of people felt that patients were at risk when there is no physician supervision of NPs or PAs.

(PPP Public Survey)

91%

of patients say say a physician’s education and training are vital for optimal care

(AMA survey)

Myths vs. Truths

Training Differences, Competency, and Clinical Judgment

Myth: “Fifty years of research, hundreds of studies, show that Nurse Practitioner (NP) care is equal or better than physician care.” AANP and corporations with aligned business interests will often make these claims.

Truth: There are NO studies that support the conclusion that NP independent practice is safe or effective.

Studies show that NPs and PAs can provide quality care in physician-led teams in patients previously diagnosed by physicians and for minor / self limited issues or specific protocols.

While at first glance, the title of the Cochrane review by Laurant et. al. “Nurses as Substitutes for Doctors in Primary Care,” can sound convincing — here’s the problem: these studies only examined primary care and in physician-led teams, not in medical specialties or in complex or undifferentiated patients.

In the Cochrane review they deemed 98% of the 9,084 articles as poor quality data to be excluded. Only 18 articles were high quality, none of which evaluated diagnostic capability and only one assessed therapeutic interventions.

  • 15 of the 18 studies were of NPs supervised in physician-led teams.
  • 14 of the 18 studies specifically excluded (i.e. NP’s did not treat) acutely ill patients.
  • Only 3 of these 18 papers were in the United States.

The studies only set out to start exploring whether nurses could help handle limited, specific tasks within primary care, not to suggest that they could—or should—replace physicians altogether.

What the Authors Actually Said: “Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing”

There is clear acknowledgment that physicians possess deeper expertise and training, that nurses can help extend the capacity of physicians in certain tasks, and that not all medical tasks are appropriate for non-physicians.

Myth: “Nurse Practitioners match physician competence.”

Truth: Research has shown that Nurse Practitioners (NPs) do not demonstrate equivalent clinical reasoning or decision-making competence to physicians.

On the only well-validated, near-equivalent exam of medical reasoning—the NBME Step 3— five years of classes of Doctor of Nursing Practice (DNP) candidates with at least nine months of clinical rotations achieved only a 42% pass rate, compared to a 98% pass rate among physician candidates.

This was even with an “NP version” of the exam where key clinical sections were omitted and and was described as “watered down.” 

Myth: “States with independent Nurse Practitioner (NP) practice have better overall health outcomes.”

Truth: There is no credible evidence that shows independent NP practice is causing improvements in health outcomes.

Similar statistical analyses can reveal other misleading correlations—such as states with more NPs also showing a significant statistical higher rate of an unrelated metric (such as opioid-related deaths, sea level rise, and deaths from bedsheet strangulation). These spurious relationships highlight how correlation does not equal causation. There is no meaningful evidence for the claim that NP independent practice of medicine leads to better or safer patient outcomes.

Myth: “The Institute of Medicine (IOM), now the National Academy of Medicine (NAM), officially endorses independent practice for nurse practitioners”

While IOM/NAM reports are usually highly respected, the 2010 report “The Future of Nursing: Leading Change, Advancing Health” was funded by the Robert Wood Johnson Foundation, to the tune of millions of dollars. They selected the committee members who would write the report, and they consisted of people with strong ties to nursing advocacy. This funding and selection process were major conflicts of interest, and resulted in recommendations that favored the priorities of the sponsoring organization rather than being an independent, objective report.

Myth: Non-Physicians provide the same quality of care.

Rates of death and complications were lower when MD/DO anesthesiologists directed the anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/

When supervision is removed from midlevels, they are 20 times more likely to overprescribe opioids. https://pubmed.ncbi.nlm.nih.gov/32333312/

The proportion of psychotropic medication prescribed by psychiatric NPs increased by ~51%, and ~29% when prescribed by non-psychiatric NPs. By contrast, physician prescribing decreased by ~55% for psychiatrists and 32% by other MD/DO’s. https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/

PAs performing skin biopsies had more missed cancers and more unnecessary biopsies relative to MD/DO dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082

NPs referred more often to heart, endocrine, and kidney specialists compared to physicians. NPs were more likely to prescribe inappropriate medications for patients with diabetes compared to physicians.  https://onlinelibrary.wiley.com/doi/10.1111/jgs.13662

Myth: Graduating with a doctor of nursing practice degree is the same as graduating medical school.

Truth: Doctor of Nursing Practice (DNP) and Doctor of Medical Science (DMSc/DPAS) degrees are administrative, not clinical degrees.

To begin with, NP and PA programs require far fewer clinical hours than medical school and residency.

NPs and PAs who pursue degrees for DNP and DMSc/DPAS will find the curricula are largely administrative, with coursework in leadership, health policy, and quality improvement, rather than rigorous clinical diagnosis and treatment of medical school.

Following the ACA’s $200 million investment in NP education, for-profit and online NP programs expanded rapidly, some requiring as little as 500 clinical hours for graduation.

Many programs have high acceptance rates, with the national average at 66%, and in 2021, nearly 60% of Family Nurse Practitioners graduated from mostly or fully online programs—far less rigorous than traditional physician training.

The DNP degree was created by Mary Mundinger at Columbia University with a clear vision: to establish a clinical doctorate for nurses while providing “title parity” with physicians. However, a later study by Mary Mundinger herself noted that only 15% of DNP programs were clinical in nature, with the remaining 85% focused on leadership and research. She described this as a “potential crisis in Nurse Practitioner education,” highlighting that the degree has largely failed to provide the rigorous clinical training necessary for safe, independent practice. https://pubmed.ncbi.nlm.nih.gov/30943837/

Myth: “Nurse Practitioners practice medicine like physicians”

Truth: Nurse Practitioners practice advanced nursing, while physicians practice medicine – entirely different disciplines.

Nursing diagnoses and care plans focus on patient symptoms and human responses to illness.

For example, patient complaint: pain in my back. nursing diagnosis: low back pain and nursing treatment: naproxen.

Medical diagnoses and treatment involve a systematic, analytical approach that incorporates patient symptoms, normal physiology, pathophysiology, objective data in the physical exam, lab results, imaging results, all toward formulating a set of potential different diagnostic possibilities (the differential diagnosis) and the most appropriate next evaluation tests and/or treatments.

For example, patient complaint: pain in my back. Medical differential diagnosis: consider and rule out aneurysm, osteomyelitis, shingles, lyme, tumor, lumbar radiculopathy, autoimmune, etc. Treatment: depends on the evaluation and final working diagnosis.

It is important to distinguish between physicians’ and nurses’ capabilities because the standards of care and legal accountability differ.

Physicians are held to a medical standard of care, whereas NPs are held to a nursing standard.

Even in states requiring physician supervision, if malpractice occurs, the physician is often held liable—highlighting the fundamental difference in training and responsibility.

Costs of Care, Access, and Rural Health

Myth: “Independent NPP practice will solve the rural or primary care shortage and improve access.”

Truth: Evidence shows, despite promises, nurse practitioners have not moved to rural areas even after legislators removed physician supervision and collaboration.

These studies showed that NPs strongly prefer to practice in urban areas and based on preferred schedules, similar to physicians. 

Even the federally funded Graduate Nurse Education project (5 years, $185 million, 5 schools), which specifically aimed to place NPs in rural areas, only yielded 9% of the 3,900 NP graduates actually choosing rural locations. 

Despite a growing 27 states which grant NPs independent practice, there has not been a state which has solved their physician shortage and rural healthcare shortage issues. 

The American Medical Association mapped the locations of primary care physicians and nurse practitioners (NPs) nationwide in 2013, 2018 and 2020. Each time, the results showed physicians and nurse practitioners tend to practice in the same areas of the state—regardless of state scope of practice laws.

This 2020 JAMA article showed that while there has been an overall increase in practitioners, there was worsening geographic disparities between rural and urban areas, due to the density of nurse practitioners and physician assistants increasing faster in urban counties than in rural counties. 

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772305

Myth: “Allowing NPP’s unsupervised practice of medicine will solve the physician shortage”

Truth: NPP’s are not equivalent to physicians; we need more physicians to address the shortage of trained physicians.

The real cause of the physician shortage is the caps on medicare-funded physician residency slots, the maldistribution of physicians across regions and specialties, and systemic pressures (such as low reimbursements, prior authorization hassles) that push physicians to work part-time, leave clinical practice for administrative or non-clinical roles, or retire early.

Corporations using NPP’s to replace physicians, instead of having the NPP’s actually support physicians (as paralegals support lawyers) does not address these root causes, and cannot solve the physician shortage issue.

In fact, the rapid growth of poorly regulated NPP programs is already projected to lead to an oversupply of NP/PA’s, without changes to scope of practice, while critical shortages persist among bedside nurses.

In 2025, the U.S. faces a deficit of approximately 78,610 full-time equivalent (FTE) RNs, with ongoing shortages projected through 2030 (63,720 FTEs). Nonmetro areas are particularly affected, with shortages of 13% in 2025 and 9% by 2030.

Real-world examples highlight the consequences of replacing physicians. When a neurosurgery residency program closed, the hospitals had to hire 23 non-physician practitioners (NPPs) to cover some of the work formerly performed by 10 residents.

https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/Nursing-Workforce-Projections-Factsheet.pdf

Myth: “Independent practice will bring an influx of NPs and large economic benefits.”

Truth: Data from North Carolina and other states revealed no substantial workforce growth after independent practice was allowed to NPs. There was no large economic gain compared to supervised states.

Myth: “Most Nurse Practitioners pay physicians large fees for collaborative or supervisory agreements, creating unfair financial burdens.”

Of the 20% who did pay a fee, only 18% and 21% reported paying directly out of pocket to establish or maintain their collaborative practice agreement (CPA), respectively. This means only approximately 4% of NPs had to pay a fee directly – and these payments were reportedly a median of $650 to establish a CPA and $500 per month to maintain the CPA. Removing physicians from the care team would not reduce disparities or improve outcomes; it threatens patient safety, especially in high-need and rural communities.

Non-Physician Practitioner “Consensus”

Myth: “Most Nurse Practitioners support independent practice.”

Truth: Evidence shows that the majority of NPs themselves do not support independent practice without physician oversight.

In a survey of nearly 400 NPs, 82% said new NP graduates are not competent for unsupervised practice.

Leaders within the NP education community – such as Jamie Lee and John Canion – have called for stronger education standards and increased supervision. These efforts and reports (e.g., “2023 Report on NP Education and the need for Change”) have been rejected or ignored by major nursing organizations like AANP and CCNE. The prevailing view among NP’s favors ongoing physician supervision to enhance patient safety and care quality, and recognizes substantial gaps in NP training and standards.

Myth: “Nurse Practitioners are prepared to provide independent care in the Emergency Department.”

Truth: Nurse researchers published in the Journal of Nursing Regulation a study showing extensive variability in NP education, licensure, and certification for NPs who are employed to work in ERs.

Only 10% of NPs in the ER had any formal emergency training, and some family nurse practitioners (FNPs) can qualify for emergency NP certification with just continuing education credits. They conclude: “Until this variability is resolved, we conclude that NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety.”

Read the Study > https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102

Myth: “NPP’s deserve pay parity with physicians, and higher reimbursement will increase their salaries.”

Truth: Increases to physician reimbursement have not increased employed physician salaries.

According to the Bureau of Labor Statistics, the vast majority of NPs — 95 to 98% —are employed by hospitals, clinics, or other healthcare organizations, not self-employed. Any increase in reimbursement for NP services will only flow to the employer, not the NP.

Oregon provides a real-world test: in 2012, the state required insurers to reimburse NPs at the same rate as physicians, and made this permanent in 2017. Despite this “pay parity,” NP wages in Oregon have not increased relative to other states; in fact, average pay has DECREASED. The extra reimbursement goes to the employer, not the NP, highlighting corporate interests being promoted by organizations like AANP, and not the interests of individual nurses.

Many professions have team members with overlapping duties, yet they are not paid equally: paralegals vs. attorneys, nurses vs. nursing assistants, bookkeepers vs. CPAs, and physical therapy assistants vs. physical therapists. The same principle applies in healthcare.

What the Research Shows

They found that NPs spending, when risk-adjusted for patient complexity, was about $28.5 M annually greater than that of physicians.

The bulk of the higher cost came from increased test orders, specialist referrals, and more patients being sent to emergency medicine departments.

At the same time physicians provided better care on nine of ten quality measures, with double-digit differences in flu and pneumococcal vaccination rates.

Read More > https://www.physiciansforpatientprotection.org/study-mississippi-concludes-non-physician-care-costs-more/

Nurse practitioners tend to order more lab testing, more imaging, and make more unnecessary referrals than physicians do, which drives up the cost of healthcare.

https://www.fiercehealthcare.com/providers/ed-docs-offer-better-care-nurse-practitioners-says-research#:~:text=However%2C%20the%20paper%20states%20that,of%20NPs%20relative%20to%20physicians.%E2%80%9D

After private equity acquisition, hospitals reduce staffing and salary expenditures—particularly in emergency departments and ICUs—leading to worse patient outcomes. ED mortality increased by 13%, transfers to other hospitals rose, and ICU lengths of stay shortened, highlighting the risks of profit-driven staffing cuts in critical care settings.

The US Department of Health and Human Services (HHS) released a report that criticizes how private equity and decreased competition is creating harmful consequences for patients seeking healthcare. It’s even increasing patient deaths.

The report found multiple studies have demonstrated hospital-system-led acquisitions and mergers are associated with higher prices for services charged to insurers and patients (between 6% and 65% higher) and can increase significantly for neighboring hospitals as well.

Several studies show no improvement in quality of care after consolidation, even negative impacts – such as increased risk of death in heart attack patients, longer travel times, and cutting of key services.

Private equity acquisitions in particular have been found to have patient-harming, cost-cutting measures such as lower staffing levels and hiring inadequately credentialed staff, while simultaneously inducing demand and volume for unnecessary tests and procedures, leading to physician burnout and less time for patients with their physicians.

https://www.hhs.gov/sites/default/files/hhs-consolidation-health-care-markets-rfi-response-report.pdf

https://www.physiciansforpatientprotection.org/the-guardian-us-health-department-condemns-private-equity-firms-for-role-in-declining-healthcare-access/