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Articles Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in California ARLYSS L. ANDERSON, RN, CS, FNP, MSHS, and CATHERINE L. GILLISS, DNSC, RN, CS, San Francisco, California
California's health care industry includes workers prepared in many ways to perform many jobs. One significant group of health care workers prepared to provide care that often overlaps with physiciangenerated services is known as "nonphysician providers." Commonly, this label refers to nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). In this article, we will describe this group in five main areas: (1) the characteristics of the current and projected workforce and programs preparing these professionals; (2) the current skill expectations and knowledge bases of each; (3) trends in the education of these health professionals; (4) innovative models of education of these health professionals; and (5) the inclusion of NPs, PAs, and CNMs in workforce planning in a changing health care system. We conclude that, particularly in light of the overlapping functions of this provider group with many physician functions, the NP, CNM, and NP workforces must be recognized and considered when planning for the future of the physician workforce. (Anderson AL, Gilliss CL. Nurse practitioners, certified nurse midwives, and physician assistants in California. West J Med 1998; 168:437-444)
he "nonphysician" workforce in California will be defined in this article as nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). Although other nurses and professionals such as physical therapists, chiropractors, and "alternative providers" perform valuable services, the NPs, CNMs, and PAs share many overlapping functions with physicians and have been shown to be competent or superior substitutes for physicians in many settings.' The origins of each of these three professional groups vary. However, their early acceptance was largely a function of their ability to extend physician services. As such, questions of collaboration and independence have characterized their struggle with organized medicine throughout the past 30 years. Certified nurse midwives originally brought obstetrical care to women in rural locations as early as 1925 through the Frontier Nursing Service in rural Kentucky. Using nurses trained in Britain as midwives, the success of this early program led to the development of the first recognized midwifery education program in the United States in 1931 by the Maternity Center Association at the Lobenstine Clinic in New York City. Nurse-midwifery in California had its first official demonstration T
in the Madera Project in 1960-1963 where neonatal mortality and prematurity declined significantly using then-called "obstetric nurse assistants." Nurse-midwifery was accepted as a specialty by nursing in 1968 and "legalized" in the state in 1975. California now has six education programs, largely within the University of California (UC) School of Nursing system. Physician assistant programs were initiated in the mid-i1960s as corpsmen returned from the Vietnam War. Although early trainees were prepared for work under the direction of physicians in acute care and specialty practices, the 1985 Health Professions Training Assistance Act (PL 99-129) required PA educational programs to emphasize primary care. Programs have traditionally been nondegree programs, offering a certificate of completion and the opportunity to write national examinations as a standardized measure of competence. Nurse practitioner programs began as nondegree programs in mid-1960s and by the late 1970s were common in graduate programs in nursing. The NP role was originally developed by Loretta Ford, MD, and Henry Silver, MD, in Colorado where nurses were trained in physical diagnosis and treatment in pediatric primary care settings. Over time, the role and educational pro-
From the Office of the President, University of California, San Francisco, School of Medicine. Prepared for The Commission on the Future of Medical Education, University of California, Office of the President, Health Care Research Group, Oakland, Califomia, January 1997. There are five appendices available with this article. Please contact Arlyss L. Anderson, at the address below, for more information. Reprint requests to Arlyss L. Anderson, RN,CS, FNP, MSHS, 401 Miner Road, Orinda, CA 94563. E-mail:
[email protected].
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ABBREVIATIONS USED IN TEXT ACNM = American College of Nurse-Midwives BRN = Board of Registered Nursing CNM = certified nurse midwife HMO = health maintenance organization NONPF = National Organization of Nurse Practitioner Faculties NP = nurse practitioner PA = physician assistant UMG = unlicensed medical graduate
have extended into other age groups and focus on the primary care needs of a segment of the life cycle (pediatrics, adults, geriatrics, and women's health) or the entire family (family nurse practitioner). As the roles have evolved and the graduates increased in number, the NPs, CNMs, and PAs have been valued for their ability to substitute for physicians in many situations and to complement physician services with strengths in communication and counseling, health promotion and disease prevention, and case management. These strengths add value to a health care team, as discussed recently in the Institute of Medicine's report, Primary Care: America's Health in a New Era.2 The model of training used in NP, PA, and CNM programs has been largely problem based, teaching additional basic science material in the context of common problems experienced in the settings for which students are being trained. In addition, early immersion in clinical settings and a preceptorship model with extensive clinical experience has permitted accelerated learning for students entering programs with the standard requirement of significant prior health care experience. Training costs for each nonphysician NP, CNM, and PA student in California have been estimated at approximately $40,000 per student3 in these two-year programs, largely paid by student tuition and fees and some state funds. This figure contrasts with the costs of physician training, estimated at approximately $800,000 per student, including residency, with significant portions covered by federal and state funds in addition to tuition and fees.4 grams
Current and Projected "Nonphysician" Workforce in California: Numbers and Characteristics NPs and CNMs
Although indexing the registered nurse workforce is complex, due to licensing in multiple states, high levels of interstate mobility, and the two-year interval that commonly occurs between relicensing, the Health Resources and Services Administration's Bureau of Health Profession's Division of Nursing has developed several national databases that describe the registered nurse workforce and the certified NP and Clinical Nurse
NPs, CNMs, and PAs-Anderson and Gilliss
Specialist workforce. Because of the sampling strategy and the relatively small cell sizes representing states in these databases, estimating the state workforces is not as reliable as surveying the state workforce. Several attempts have been undertaken in California. In 1993 Morgan5 estimated that the total number of actual California NP licensees, as reported by the Board of Registered Nursing (BRN), should be reduced by 13% to account for dual state licensure. A 1995 study of California NPs' reported that 85% of the respondents were active in the workforce. Taken together, with current information from the BRN, these corrections aid us in more predictably estimating the active NP workforce in California. As of March 1996, the BRN records indicated that 6,991 NPs were licensed to practice in California. Correcting for dual licensure and inactivity finds this figure reduced to 5,170 practicing California NPs, a 20% increase over the 1995 figure. This figure translates to approximately 16 NPs per 100,000 population, which contrasts with 185 per 100,000 for nonfederal, patient care physicians (excluding residents). Based on data of the 1995 NP Data Base Project (N = 2,741), UC trained the largest segment of responders, 45%, and the California State system trained the next largest at 18%. Eighty-six percent of respondents were trained in California programs, with only 14% of respondents trained out of state. Of the 2,741 responders, the largest specialty group were the family nurse practitioners (37%), followed by the women's health care NPs (25%), Pediatric NPs (19%), adult NPs (18%), family planning NPs (12%), gerontological NPs (7%), school NPs (4%), CNMs (4%), occupational NPs (3%), and psychiatric NPs (1%). Eight percent of those surveyed identifying themselves as "other" most often represented obstetrics-gynecology, neonatal, and other acute care specialties (total >100% due to dual specialization) (Figure 1). The majority of responders held master's degrees (56%), followed by 26% with bachelor's degrees, 9% with associate degrees, 6% with diplomas in nursing, and 2% with doctoral degrees. Among those currently in practice, most (66%) worked in primary care. Fifty-six percent of respondents stated that they had worked or were now working in a medically underserved area. Populations served by respondents included uninsured (served by 51% of sample), ethnic minorities, women and children (served by 54% of the sample), and insured or self-pay patients (served by 60% of sample). Seventy-six percent of responders reported full-time-equivalent salaries in their principal positions ranging from $40,000 to $69,999, with 12% earning greater than $70,000 and 12% earning less than $39,999. Almost a third of the sample reported holding more than one job. Responders were predominantly in their 40s (47% aged 41 to 50), most were female (96%), white, non-Hispanic (85%), and married (66%). In 1996, the BRN listed 822 CNMs licensed to practice in California. This figure represents a 12% increase from 734 in the summer of 1994. According to Judson and Flannagan,7 83% of CNMs are currently practicing.
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|Women's Health 25%
Family Practice 37%
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Family Planning 12| Pediatric 19% _
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* Adult
Figure 1.-Specialties of nurse practitioners in California.
This would reduce the number of practicing CNMs to approximately 682. The majority of California CNMs (57%) were prepared in California, the largest number having been prepared at the UC-San Francisco (UCSF)/San Francisco General Hospital Program, which just celebrated its 20th anniversary. Fifty-two percent of CNMs hold a master's degree in nursing or another field, but the midwifery credential was earned as part of a certificate program of study in 67%. Forty-one percent of CNMs have been practicing for 10 years or longer, and most are working full-time (67%), as employees of physician groups (21%), hospitals (17%), or health maintenance organizations (HMOs) (16%). Only 30% report having a second employer. Most (72%) report having clinical responsibilities with births, and 61% report earning more than $60,000 annually. Respondents were virtually all female, predominantly white (89%), and in their 50s (42%) or 40s (39%). Physician Assistants The California Physician Assistant Examining Committee, the state agency that licenses PAs, indicates that in August 1996, 2,556 PAs were licensed in California and residing in the state. This translates to about 8 PAs per 100,000 population, a slightly lower ratio than the NP ratio (16) and much smaller than the physician ratio (185 per 100,000). The American Academy of Physician Assistants in Virginia maintains the most accurate database currently on PAs in California, although not all PAs are members. The 1994 member census survey (N = 1,016) reports that 53% of California PAs were practicing in a generalist field (family practice, general internal medicine, and general pediatrics) as compared with 38% of physicians, and 66% of NPs. In 1996 the percentage of PAs practicing in a generalist field increased to 56.7%, with 47.7% in family practice, 5.7% in general internal medicine, and 3.3% in general pediatrics (American Academy of Physician Assistants, unpublished data, January 1997) (Figure 2). California's PA workforce, like its physician and NP
CNMs,
and
PAs-Anderson
and Gilliss
and CNM workforce, is largely white, non-Hispanic (76%). The African American percentage of the PA workforce is about the same as the state's population (8%) (Table 1). The 1996 female-to-male ratio was much smaller than the NP ratio, being approximately 48:52. Income for PAs in California is slightly higher than that of NPs, with the mean income at $69,677 (1996); the mean salary in generalist fields, however, is comparable.8 Only 46% of California's PAs were educated in the state and only 8% in the UC system. Seventeen percent were trained in the University of Southern California program, which had the highest percentage of graduates practicing in the state. Credentials received by responders through their PA education were reported as 47% certificates as PAs, 12% two-year degrees, 39% bachelor's degrees, and 2% master's degrees. Before PA education, 54% had received a bachelor's degree, 30% an associate degree, 5% a master's degree, and 1% a doctorate. NP and CNM Programs All five UC health sciences campuses offer programs for NPs or CNMs. Enrollment of first-year students in UC's primary care NP programs increased by 50% between 1990 and 1995, rising from approximately 140 to 270 new students per year.9 First-year enrollment of CNMs was stable during this period at approximately 30 students. Responding to a survey developed by the California Strategic Planning Committee for Nursing in 1994, directors of generalist NP programs in California indicated that they planned to increase enrollment of new students by 21% between 1994 and 1997, from 542 to 658 new students. Directors of specialist NP programs anticipated increasing enrollment by 10%. Enrollment of new students in CNM, certified registered nurse anesthetist, and clinical nurse specialist (CNS) programs was expected to increase more slowly. Nationally, there has been a significant increase in NP training programs from 253 clinical tracks in 119 institutions in 1992 to 527 clinical tracks in 202 institutions in 1995. This represents a 69% increase in the number of institutions offering NP programs and a 108% increase in available clinical tracks for NP students.'0 This rate of growth has not been seen in California, and program directors throughout California cited numerous obstacles to enrollment expansion.6 These were lack of program funding base (91% of programs), the inability to pay competitive salaries (68% of programs), difficulty finding qualified faculty (59% of programs), difficulty locating clinical practice sites for students (55% of programs), and lack of financial support for students (23% of programs). PA Programs Only the UC-Davis campus currently offers an educational program for PA preparation within the UC system. The UC-Davis program is a combined FNP-PA program whose graduates are eligible for licensure as
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Skill and Knowledge Base of Today's NP, CNM, and PA nhu2f,vn u %-, y di. .
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Ermergency Medicine Medical sub
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Surgical sub-spec 15%
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Figure 2.-Specialties of physician assistants in California.
NPs and certification as PAs if nurses or certification as PAs if a nonnurses. All other PA programs in California are based at private institutions (Charles Drew University, Stanford University, University of Southern California, Western University of Health Sciences). The Stanford program is also a combined FNP-PA program similar to the UC-Davis program. None of these programs offers a degree. Nationally, the total number of PA programs has increased from 55 in 1990 to 81 in 1995, with an increase in the number of graduates from 1,630 in 1990 to 1,956 in 1995 (120% increase).'t In addition, there has been a 367% increase in applicants during this period. The applicant pool to PA programs throughout the nation differs significantly from those of NP programs by the varied health care and academic backgrounds. In addition, PA programs have attracted unlicensed medical graduates (UMGs) as applicants to their programs. Nationally, UMG applicants to PA programs have decreased from 143 (3.0 per program) in 1994 to 123 (2.1 per program) in 1995. Unlicensed medical graduate enrollment has increased slightly from 22 in 1994 to 24 in 1995. Decreasing percentages of UMGs are successful in gaining acceptance to PA programs nationally, completing the programs, and passing the national board examination.'2 In California, an experimental program was established at Stanford University to train UMGs and reported that "none of the international medical graduates at entry or exit showed the equivalent level of clinical knowledge or skills expected at the end of PA training."'2(P891) Reading comprehension and command of the English language appear to be major barriers for this group. It is anticipated that the academic preparation of entering students will increase due to the increased applicant pool, and therefore, attrition rates, which have been an issue, may be expected to decrease proportionately as the average student has a higher aptitude for PA education. "
NPs and CNMs Given that the majority of NP programs reside within graduate nursing programs (National Organization of Nurse Practitioner Faculties [NONPF], 1996), a quick overview of graduate nursing curriculum is instructive. The graduate curriculum as proposed by the American Association of Colleges of Nursing includes three general areas of instruction: graduate nursing core curriculum, advanced nursing practice core curriculum, and a nurse practitioner specialty curriculum. The graduate nursing core, including the advanced nursing practice core, adds the components for the complex tasks of overall health assessment, diagnosis, and management of health and illness. The nurse practitioner specialty content builds increasing depth in the chosen area of specialty (Figure 3). This model has been developed recognizing the importance of the placement of advanced nursing practice within the framework of graduate education, and in California, most NP programs are now at the master's level. The model is appropriate for all clinically based curricula for advanced practice nursing, and includes approximately 600 clinical hours in addition to approximately 500 didactic hours. The areas of graduate education in nursing administration and community health, where students are not generally prepared to provide direct patient care, do not generally include the advanced practice nursing clinical core. Most NP programs in California are based on this model, although the UC-Davis program differs as it is not part of a school of nursing, but of the Department of Family Practice in the School of Medicine. The UC-Davis NP curriculum does not include the graduate nursing core, but is otherwise similar. Clinical hours in this program are approximately 1,350 and didactic hours approximately 600. Those NPs interested in a master's degree attend additional courses offered through California State University, Sacramento. Efforts have been undertaken or are now under way to identify core areas of skill and competence for NPs, CNMs, and PAs. Both the NONPF and the American College of Nurse-Midwives (ACNM) have undertaken TABLE 1.-CCalifornia NPs and PAs by Race/Ethnicity* Racial/Ethnic Group
African-American Asian/Pacific Islander Latino Native American/Other White Total
NPs
CNMs
PAs
3% 6% 4% 2% 85% 100%
4% 2% 3% 2% 89% 100%
8% 6% 9% 1% 76% 100%
*From the AAPA, 1994 Membership CenisLJs database:
Gillissr and ludson arnd Flannagan.
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Nurse Practitioner Specialty Specialty Management Content Clinical Practice Specialty Role
Advanced Nursing Practice Core Health Assessment Pharmacology Pathophysiology Clinical Decision making Health Promotion/Disease Prevention Community-based Practice Role Family Theory
Graduate Nursing Core Research Health Policy Nursing and Health-Related Theory Organizational Theory Ethics Cultural Diversity Community-based Care Health Care Economics Health Care Delivery Systems Managed Care Figure 3.-Components of nurse practitioner education.
major revisions in core competencies in the past few years. The ACNM has been a pioneer in this area, and their latest (1993) revision of the competencies appears in Appendix I. (For more information about the five appendices available with this article, please contact Arlyss L. Anderson, RN, CS, FNP, MSHS, 401 Miner Road, Orinda, CA 94563; e-mail:
[email protected]. edu.) Although not addressing the "managed care environment" or cost issues directly in the competencies, the ACNM has included quality of care, social science, and public health skills in their competencies. These areas coincide with the "Global Core Competencies for Health Professions" suggested by the Pew Health Professions Commission (1993), which appear in Appendix II. The NONPF, whose board has endorsed the global competencies developed by the Pew Health Professions Commission, has specified six major domains or clusters of competencies that have similar intentions, functions, and meanings (Figure 4). These competencies are based on the overall goal of NP practice, which is to promote and restore health. Competencies, or skills and knowledge necessary for each person to demonstrate are developed within each domain (Appendix III and IIIA). Physician Assistants The overall goal of PA education is to prepare students academically and clinically to provide health care services with the direction and responsible supervision of a doctor of medicine or osteopathy. The "Essentials and Guidelines for an Accredited Education Program for the Physician Assistant" describes the curricular areas necessary to provide the appropriate skill and knowledge base.'3 The PA is trained to perform diagnostic, therapeutic, preventive, and health maintenance services in any setting where the physician renders care. Core educational components for PAs are detailed in Figure 5. Programs preparing specialty PAs will include additional specialty focused curriculum. Services perforned by the PA include evaluation, monitoring, diagnostics, therapeutics, patient education and counseling, and referral. All PA programs in
and Gilliss 441 Gilliss 441 NPs, CNMs, and PAs-Anderson and
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California provide education toward national certification as a PA, and two provide additional course work toward a bachelor's degree. Current Curricular Trends in the Education of APNs and PAs Trends in the education of NPs, CNMs, and PAs have many parallels in both the number of graduates and the characteristics of the educational programs. Fueled by predictions in the late 1980s and early 1990s of insufficient numbers of providers of primary care services, as well as market demand for graduates, programs training NPs and PAs have increased in number and capacity, as described earlier. Several additional trends are evident: concern for geographical distribution of graduates, with renewed commitment to community-based and community-relevant education; cultural sensitivity and workforce diversity; and a move toward curricular standardization. Geographical Distributions The trend of training NPs, CNMs, and PAs for practice in rural and underserved communities that began in the early 1970s continues today, with renewed vigor. All federal predictions of workforce supply continue to note rural and underserved communities are likely to be the last to experience appropriate levels of health professional support. Efforts to provide these communities with NP, CNM, and PA professionals through recruitment and flexible training modalities have been successful. UC-Davis has implemented a program of study that offers the opportunity to live and practice in communities far from the educational site. Using local preceptors for all clinical training and off-site faculty for evaluation, this program has contributed significantly to the development of the primary care workforce in Northern California and the San Joaquin Valley. UCSF is now beginning to develop distance technology for educational broadcasts to distant California communities to improve access to education in remote areas. Recent research has shown that 85% of the NP workforce in the Fresno area was trained in Fresno (A.A.A., C.L.G., "California Nurse Practitioner Database," unpublished data, 1995). Population Diversity The health care workforce of California has failed to mirror the population in its ethnicity. Recently Management of Client Health/Illness Status: Health Promotion and Disease Prevention Management of Client Illness Nurse-Client Relationship Teaching-Coaching Function Professional Role: Managing and Negotiating Health Care Delivery Systems Monitoring and Ensuring the Quality of Health Care Practice Figure 4.-The domains of nurse practitioner practice (from the National Organization of Nurse Practitioner Faculties, 1995).
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Patient Assessment Role of the PA Interpretation of Medical
Figure 5.-Core educational content areas for PAs (from the American Medical Association13).
Komaromy and colleagues'4 demonstrated that black and Latino providers were more likely to practice in poorer communities than non-Hispanic white physicians and in communities with relatively high rates of people of their own race and ethnicity. A similar analysis of data from the 1995 California NP Data Base6 found similar patterns for California NPs. Programs at UC-Davis have been successful in increasing the number of underrepresented minorities and especially Latinos, a group that is poorly represented in health care. Latinos accounted for 24% of students in 1995, roughly equal to the percentage of Latinos in California's population. Standardization in Curricula Another trend that is shared by NP, CNM, and PA training programs is the move for standardizing curriculum, with the expectation that this can improve the quality and mobility of graduates, as well as create "product" reliability. Both NONPF and the ACNM have developed the previously discussed core competencies, curriculum guidelines, and program standards. The American Academy of Physician Assistants is currently developing these competencies in addition to program "Essentials and Guidelines" that have been in place since 1971. Nurse practitioners, CNMs, and PAs all have national certification examinations that promote the standardization of preparation for entry into practice. For NPs, however, these examinations are only required for recognition in some states, and most of the examinations may only be taken by NPs who hold a master's degree in nursing. In addition, there are four examinations and examiner organizations for NPs in the United States, whose requirements and focus vary slightly. Currently, there is a movement to standardize these NP credentialing mechanisms. The placement of clinical NP education within the framework of graduate nursing education is a continuing national trend. With the exception of UC-Davis and some private programs, most CNM and NP programs in California require the completion of a bachelor's degree for admission and are offered as part of a master's degree in nursing. This has not been mandated in California as it has through practice act changes in some other states. As of 1995, 57% of NPs practicing in California held a master's degree or higher.'5 Physician assistant programs are also increasing the credentials offered through training. Nationally, 61% are awarded a baccalaureate degree on graduation, and 18.8% are awarded a master's degree." As of 1996, there were 14 PA programs in the United States that offer a master's level of credentialing on graduation. None of these are in California.
PAs-Anderson and and Gilliss Gilliss NPs, CNMs, and PAs-Anderson
NPs, CNMs, and
Innovative and Promising Methods of Instruction Innovative methods of instruction have been developed in NP, CNM, and PA programs throughout the nation and California. Models of greatest interest are those addressing the current maldistribution of health care professionals and those addressing interdisciplinary practice. Currently there are a few programs that are of special note. Maldistribution Although most program directives interviewed for this report indicated that their programs work toward the training of professionals for underserved areas and communities and offer admission priority for those whose career plans are so described, bringing students into the traditional University setting for their education often removes them from the communities they plan to serve later and fails to provide relevant context for future practice. The UC-Davis FNP-PA program has a long history of addressing this problem through satellite didactic sites throughout the state and flexibility of these locations based on training needs within the state. Beginning in 1976 with funding from the Robert Wood Johnson Foundation, UC-Davis has developed modular programs and curricular design that adapt well to students in rural and underserved sites. In addition, the curriculum and overall organization of the program has been designed to permit students to remain in remote settings for the bulk of their training, coming to the didactic training site for only a three- to four-day block per month for intensive didactic teaching. The didactic training sites are, themselves, decentralized into a "satellite" network that can be moved to different areas of the state dependant on need. Students and preceptors from underserved and rural sites are given priority in admissions and supported to remain in their home communities throughout the twoyear program, with faculty traveling to those remote practice sites. The curriculum has been developed in a modular format to permit independent, self-paced learning. This program has demonstrated success in preparing students for primary care underserved and rural practice. The percentage of 1996 graduates practicing in primary care is 84%; 76% of them are in defined underserved areas, and 48% are in rural areas. This compares with the overall professional figures of approximately 10% in rural areas. A planned development of distance technology at UCSF to permit remote educational broadcasts has great potential for further addressing the problem of maldistribution. Outside of the UC system, the NP program at California State University-Sonoma (on the outskirts of the San Francisco Bay Area) has developed a distance learning system that educates students who choose to remain in more remote Humboldt County. Modular, internet, and remote clinical programs have been in place on a national level for CNMs for six years through the Frontier Nursing Program in Kentucky. This regionalized clinical practice model and computerized
443 NPs, CNMs, and PAs-Anderson and Gilliss 443
WJM, May 1998-Vol 168, No. 5 network for learning has had excellent results based on the national standardized examination and evaluation. This program is noteworthy in that it is able to train hundreds of midwives at a time rather than the few normally enrolled in traditional nurse midwifery programs. In addition, this model has had impact by paying preceptors for their training time. This has decreased the number of available clinical preceptorship sites here in California for UC students. Similar programs are being developed at the State University of New York at Stony Brook, and all have the potential to include California enrollees. Interdisciplinary Training NPs and PAs together has proved successful at UC-Davis and Stanford University. In Fresno, California, a faculty community group has been working since December 1994, and since July 1995 with support from the Robert Wood Johnson Foundation, in an effort to combine the training of PAs, CNMs, and NPs. Directed by the San Joaquin Health Consortium, the Central Valley Health Education Partners (UCSF, UCSF-Fresno, UC-Davis, Planned Parenthood, Stanford University, and UCSF Center for the Health Professions) are developing a shared curriculum that matches didactic content and clinical practice to the needs of the region and more clearly recruits community members matched to the population characteristics of the region into these programs. Initially funded for two years of planning, the project is proposed for implementation between fall 1997 and spring 2003. The proposed project will employ a combination of distance education strategies-class broadcasts, telemedicine, computer assisted instruction, and self-paced modules-and local clinical supervision to offer a curriculum in which PAs, NPs, and CNMs jointly participate in relevant offerings. The primary outcomes for this effort are expected to be: a more diverse graduate program, a graduate group prepared for and committed to the region, a graduate group better versed in the preparation of other midlevel providers and better prepared to cooperate in practice, and a more resource-efficient use of program resources. The interdisciplinary training of physicians and NPs, PAs, and CNMs is occurring informally in many UC training sites, but, at present, no formal programs are in place. The exposure of physicians to these professionals during medical school and residency programs has increased with increased employment of NPs, CNMs, and PAs within the system.
NPs, CNMs, and PAs in the Emerging Health Care System Inclusion in Workfforce Planning Making assumptions about the future numbers of trainees proves difficult given the tumultuous nature and questionable direction of health care today. In light of current market changes and some predictions of an adequate or possible oversupply of primary care profession-
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als, there is a great deal of interest and speculation regarding future demand for these professionals. With "the market" in control and the industry calling for the highest quality service for the lowest cost, will demand increase-based on their well-established ability to provide high-quality primary care services with lower education, training, and payroll costs? Or will demand decrease due to an increased pool of physicians seeking positions for lower wages? Other than strict substitutability, are the complementary skills of communication and counseling, focus on disease prevention and health promotion, and case management truly of value in the emerging system? In California, where the penetration of managed care has reached 70% in some areas, the demand for these professionals appears to be stable at present. Some of the variables that will likely impact this demand are HMO and individual practice association utilization rates (of NPs, CNMs, and PAs), HMO penetration rates in the state, substitutability ratios, and the value of complementary services in the marketplace. Although the provision of primary care services by interdisciplinary teams has been called for in many recent studies of primary care,"6 there has been relatively little study of team practice and its value. The members and attributes of the "health care team of the future" are yet to be determined and are likely to be highly variable, based on individual provider strengths, practice characteristics, and process and environmental characteristics. Workforce projections methodology in the past has focused solely on physician requirements. The development of the "integrated requirements model" for primary care providers by Vector Research for the US Bureau of Health Professions'7 is an innovative approach to workforce planning that includes NPs, CNMs, and PAs. This model has recently been used in Utah and in the Fresno area of California. Assuming a nationwide baseline substitution ratio of 0.4 CNMs, NPs, and PAs to each primary care physician (family practitioners, general internists, general practitioners, and obstetriciangynecologists), this model predicts primary care physician requirements of 77.7 per 100,000 population. If the substitution ratio increases to 0.5, the primary care physician requirement drops by 17% to 66.4 per 100,000. The use of a tool such as this will likely permit communities to more accurately predict overall work-
force requirements.
Conclusion Although small in number, given the overlap of functions of these professionals and the fairly significant differences in training time, training costs and professional characteristics, careful consideration needs to be given to this group of professionals in health care workforce planning. In working toward a goal of providing the highest quality health care workforce for California for the lowest possible cost to society, these professionals must be included in any workforce planning and projection.
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