Quality among a diversity of health care providers

Richard A Cooper
Med J Aust 2006; 185 (1): . || doi: 10.5694/j.1326-5377.2006.tb00437.x
Published online: 3 July 2006

Thirty years’ experience in the US with non-physician clinicians shows they can deliver quality care

Like Australia, the United States is experiencing physician shortages,1 and non-physician clinicians have become ever more important as providers of patient services. Most prominent among these are nurse practitioners (NPs) and physician assistants (PAs), as reviewed by Hooker in this issue of the Journal,2 but others also contribute to providing “physician services” in the US. They include alternative and complementary medicine providers (chiropractors, naturopaths and acupuncturists), mental health providers (psychologists, clinical social workers, counsellors and therapists) and members of several specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse-midwives). Over the past 30 years, all have struggled to obtain licensure in the various states, to expand their practice prerogatives, and to achieve broader reimbursement from third-party payers. The progress that NPs and PAs have made is evident in Hooker’s review. The question is, do they contribute to quality? This editorial will comment on NPs, PAs and psychologists. A broader review, which forms the basis for this essay, assesses the full range of disciplines.3

  • Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa, USA.



The content and ideas expressed in this editorial have been largely drawn from my previous article (co-authored with Stoflet), Diversity and consistency: the challenge of maintaining quality in a multidisciplinary workforce.3

Competing interests:

I have spoken about this subject at many professional meetings and have often been given an honorarium and usually had my expenses covered by the organisation that sponsored the meeting.

  • 1. Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med 2004; 141: 705-714.
  • 2. Hooker RS. Physician assistants and nurse practitioners: the US experience. Med J Aust 2006; 185: 4-7. <eMJA full text>
  • 3. Cooper RA, Stoflet SJ. Diversity and consistency: the challenge of maintaining quality in a multidisciplinary workforce. J Health Serv Res Policy 2004; 9 (Suppl 1): 39-47.
  • 4. Mundinger MO. Twenty-first-century primary care: new partnerships between nurses and doctors. Acad Med 2002; 77: 776-780.
  • 5. Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial of the nurse practitioner. N Engl J Med 1974; 290: 251-256.
  • 6. Sox HC Jr. Quality of patient care by nurse practitioners and physician’s assistants: a ten-year perspective. Ann Intern Med 1979; 91: 459-468.
  • 7. Office of Technology Assessment. Nurse practitioners, physician assistants, and certified nurse-midwives: a policy analysis. Washington, DC: Government Printing Office, 1986. (Health Technology Case Study 37, OTA-HCS-37.)
  • 8. Brown SA, Grimes DE. A meta-analysis of process of care, clinical outcomes, and cost-effectiveness of nurses in primary care roles: nurse practitioners and certified nurse-midwives. Washington, DC: American Nurses’ Association, 1993.
  • 9. Mundinger MO. Can advanced practice nurses succeed in the primary care market? Nurs Econ 1999; 17: 7-14.
  • 10. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians — a randomized trial. JAMA 2000; 283: 59-68.
  • 11. Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 2001; 58: 55-61.
  • 12. Speer DC, Schneider MG. Mental health needs of older adults and primary care: opportunity for interdisciplinary geriatric team practice. Clin Psychol: Sci Prac 2003; 10(1): 85-101.
  • 13. Yager J. The 2002 psychologist prescribing law in New Mexico: the psychiatrists’ perspective. Md Med 2002 Fall; 3(4): 21-23.
  • 14. United States General Accounting Office. Prescribing psychologists — DOD demonstration participants perform well but have little effect on readiness or costs. Report to the Chairman and Ranking Minority Member, Committee on Armed Services, US Senate, 1999.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.