How do non-physician providers function in HMOs?

Among the many issues that health care reform has brought to public attention is that health care in the future will be based on a primary care model, similar to the ones which have been the basis for our staff and group model HMO delivery systems for the past couple of decades. Policymakers have begun to realize that not only do our delivery systems depend upon a higher percentage of primary care physicians than the specialty-oriented, fee-for-service model, but that we also employ large numbers of nurse practitioners and physician assistants (NPs, PAs). Not surprisingly, major medical journals have recently carried several articles on non-physician providers, sometimes called mid-level or associate-level clinicians, their current roles and projected roles for the future. The sorts of issues that arise from these articles are not limited to determining the staffing patterns of the reformed health care system in the United States, but more specific and troublesome issues such as whether there is good evidence that use of mid-level clinicians is cost-effective. With a projected shortage of primary care physicians, many are interested in whether NPs can function effectively in an independent role. There is a meta-analysis of over 30 studies which indicates the effectiveness of non-physician providers, but interestingly almost all of the studies were done in managed care, such as our own, or university settings in which NPs work in collaborative teams with physicians. One critic has even questioned whether the original studies on the effectiveness of NPs are not too old to be useful.(ABSTRACT TRUNCATED AT 250 WORDS)