A second positive impact may be seen in terms of patient care offerings being made in geographic regions where physicians are unwilling to go but where NPs and PAs may be willing to practice. This is particularly true of rural areas and areas of concentration for those of low socioeconomic status. Patients in these areas tend to be most accepting of care from NPs and PAs, but other patients appreciate the efficiencies of shared NP/PA and physician duties as well as long as they feel they are receiving a high quality of care.

A potentially negative outcome of these expanding roles is that state-by-state guidelines regarding practice regulations for nurse practitioners and physician assistants vary widely. Physicians may have difficulty establishing guidelines for their own offices within state guidelines. They may also be concerned that patient care will be compromised when diagnosis and treatment of chronic medical conditions (versus minor acute illnesses) is conducted by those with less education and training with limited or no supervision, as it is in some parts of the country, such as when NPs and PAs write prescriptions or order tests that don’t have to be reviewed or approved by medical doctors.

But the most obvious impact on physicians of expanding roles of nurse practitioners and physician assistants is territorial battles over which duties may be performed by each party. NPs and PAs typically earn regular salaries versus being paid by productivity, as medical doctors are, and the more they take on, the lower the overhead. Physicians could find themselves taking a back seat to NPs and PAs in some instances as medical practices and hospitals try to save money. Physicians can also suffer when the practices of NPs and PAs reduce the relative value units used to calculate physician Medicare reimbursements.

As medical practices and hospitals try to attract more NPs and PAs to conserve expenses, they may begin offering more income incentives that more closely match those of physicians, particularly if they are highly specialized – bridging the gap between NPs and PAs and their supervising physicians. This can create resentment between the parties.

Supervision of NPs and PAs can also be a confusing area for physicians as they observe the expansion of those roles. Some hospitals and medical practices are categorizing NPs and PAs as general-duty instead of assigning them to as specific doctor, making supervision more complicated.

As the healthcare system evolves, it will be increasingly important to physicians that the expanding roles of nurse practitioners and physician assistants be integrated into an overall management system that allows for appropriate oversight and considers reimbursement for physicians as part of the equation.