These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.
“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”
Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.
“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”
This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”
But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”
Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”
Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.
But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”
Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.
Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”
As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”