A 17-part thread on independent practices legislative fights and the distractions they represent.

First, I am troubled that we continue to have these policy fights. They are a waste of time, but more importantly they are a distraction.

These efforts distract us from the real issues of creating patient-centric care systems that drive comprehensive, continuous and coordinated primary care and account for the costs incurred by individuals and families.

Independent practice laws and regulations are a 20th century solution. They simply contradict what is known today about creating value in health care and they are incongruent with high-performing 21st century health delivery systems.

But, they are 100% aligned with a profit model that seeks to drive high-volume, marginal quality episodes of care. We should seek to align resources & maximize value for patients, not create more fragmentation and silos that costs patients & the health care system more money.

I have studied primary care delivery and payment for more than 20 years and there are some truths:

1) there is no equivalency in education, training or skills between a primary care physician and a nurse practitioner – its not even close. Anyone who suggests otherwise is not serious about the facts and data.

2) there is a distinct difference in providing comprehensive primary care (physician model) and providing primary care services (NP model).

3) there is no greater value in health care than a longitudinal relationship with a primary care physician or primary care team – it has been proven over and over again.

4) primary care teams are best positioned to maximize this value for patients and health care systems and fragmentation of the team leads to higher costs and lower quality. Every clinician is important, but they are not interchangeable.

5) independent practices laws have never lived up to their promise. 50% of NPs practice full time in a true primary care practice & NPs do not go to rural communities at a greater % than primary care physicians. And, most PAs work in specialty fields of medicine – not pc

6) states with independent practice laws have not seen a demonstrable decrease in costs nor an increase in access to care.

7) why do we accept/promote a lower quality of care for rural communities? Rural communities should benefit from the most comprehensive skill-set and those skills are only found in primary care physicians – primary care, OB, mental/behavioral health, office-based surgery

NPs and PAs - even practicing at the "top of their education and training" lack the comprehensive skill set of a physician. If you want to help rural communities - put a primary care physician there.

8) NPs and PAs do, however, tend to have higher opioid prescribing rates. NPs and PAs prescribe opioids at a much higher rate than physicians, which is concerning. https://pubmed.ncbi.nlm.nih.gov/32333312/ 

8) Patient v Profit Models – it is important to understand that the motivations of those pushing NP/PA independent practice are profit driven not patient driven. They seek to maximize the number of visits & maximize the margin of each visit.

In closing, if we are serious about improving access & quality, we need to leave the failed policy proposals of the 20th century behind & focus on real solutions that maximize value for patients - not those that drive profit for tech, VC & insurance companies

Those real solutions start with increasing our national investment in primary care and making certain that every patient and every community has a primary care team led by a family physician, pediatrician or general internist.