Not What the Doctor Ordered is a treatise on the economic benefits of allowing advanced practitioners (including Nurse Practitioners [NPs], Certified Registered Nurse Anesthetists, Certified Nurse Midwives, Clinical Pharmacists, Doctors of Physical Therapy, and Doctors of Clinical Psychology) to practice independent of the control of medical doctors and organized medicine. The underlying argument is that the United States spends twice as much as other first-world nations on medical care, with similar utilization rates, with one of the drivers being physician's incomes, whereas disposable income for 90% of the population has not risen. In the latest edition, published in 2020 by Routledge/Productivity Press, Dr. Bauer argues that Americans need less expensive alternatives to obtain care. Training and competence should define who is qualified to deliver unsupervised health care, not the outdated physician as "Captain of the Ship" model that provided doctor's with economic and practice authority over other health care providers and that still prevails in many states practice acts today.

Dr. Bauer traces the beginning of the states' licensing of physicians to the US Supreme Court ruling in 1888. It took the next 30 years for every state to initiate these licensing laws. By 1910, the American Medical Association commissioned the Flexner Report resulting in standardization of medical training in university settings with an emphasis on basic science and medical schools' control over clinical instruction in hospitals. State medical practice acts defined the practice of medicine effectively legislating who could provide care. Non-physician practitioners' scope of practice was often incorporated in medical practice acts and overseen by the boards of medicine, effectively providing physicians with unopposed authority over other providers of care. Fast forward to the 21st century and the roles and education of Advanced Practitioners evolved as did their models of care. Studies in peer-reviewed journals demonstrated that, for instance, physician and NP care that overlapped demonstrated similar outcomes and were well received by consumers of that care. However, antiquated practice acts in many states still control access to advanced practitioners requiring them to work for physicians which keeps the costs of care high, entitling physicians to make a profit from these arrangements for supervision because of physician control of reimbursement.

Dr. Bauer, using the criteria from the Flexner era reforms, demonstrates that Advanced Practitioners now meet the foundational concepts for professional authority and autonomy that should allow them to practice independently in a free market, providing access to well-received and less expensive care for the consumer. University education for advanced practitioners is now often at the doctoral level, with education-based criteria and the clinical models for these practices often come from different, though no less valid, philosophies of care. Primary care, not specialized care, is a less costly avenue to the provision of care for Americans, and advanced practice nurses can provide that care, potentially decreasing costs overall and improving access if unimpeded by arcane regulations. Second, advance practitioners have their own programs of research, contributing to the body of work that produces evidence-based care. Certification and recertification for practice is now the purview of each type of advanced practice, ensuring safe providers of care. Dr. Bauer also makes the point that health reform should focus on rules to guide practice applicable to all health professionals so professional liability is uniformly applied. As an NP, this writer would give the example of the ADA Standards of Care for those with diabetes, updated annually, which applies to all health care practitioners. Independent practitioners need to have a code of ethics defining how members of the profession define their obligations to caregivers, patients, and society. In nursing, this tenet of professionalism is outlined by American Nurses Association's Code of Ethics. Quality assurance is another tenet of an autonomous profession that evaluates their own members' practices, and advanced practitioners should evaluate members within the scope of their practice. In nursing, this is the role of boards of nursing.

In 2003, as a doctoral student in health policy at Columbia University, I spent a week with Dr. Jan Towers meeting at the Centers for Medicaid and Medicare. We understood that NPs were included as providers in Medicare, but what we did not understand was why NPs were often kept off Health Maintenance Organization (HMO) panels which took Medicare patients. My job was to investigate HMOs in the 50 states and see if I could understand what was transpiring. What I found out was that, although NPs were Medicare providers, HMOs (controlled by physicians) were given the option under the Medicare rules to use NPs to care for Medicare patients, and so in physician-rich states, NPs were blocked from these organizations, but in more rural states, NPs were included in provider panels. So, when I read Dr. Bauer's book, I realized I had firsthand knowledge about the power of physicians who could protect their own incomes. Payment from Medicare was at 85% of the physician's rate for the NP. Further, many NP visits, even those of empaneled NPs, were billed under the physicians' National Provider Identification number at "incident to" rates of 100% of the physician's fee schedule, making NP care invisible. This issue was uncovered by this writer when, as a doctoral student, she attempted to use the Medical Expenditure Panel Survey to describe the contribution of NPs to patient care.

By 2010, The Institute of Medicine supported nurses practicing to the full extent of their education and training, but recognized that regulatory barriers at the state level resulted from political decisions that were unrelated to consumer safety were in need of reform. In 21 states and the District of Columbia, NPs have full practice authority. Many of these are rural states with physician shortages. In a new RAND corporation study published by the journal Health Services Research, the burden of payments as a portion of income was, not surprisingly, among households with the lowest income (Carman et al, 2020). Households with the bottom 20% of income pay, on average, 33.9% of their income toward health care as compared with those households in the top income group, which pay 16% of their income toward health care. According to the American Association of Nurse Practitioners (AANP National Nurse Practitioner Database, 2019), more than 270,000 NPs are licensed in the United States, 82.9% of full-time NPs accept Medicare patients and 80.2% accept Medicaid patients. Almost 73% of all NPs deliver primary care, an area of practice with low growth in the physician workforce (Kacik, 2020).

The first edition of Not What the Doctor Ordered was published in 1994, and 26 years later, health care reforms are still needed to provide the consumer with access to health care that is safe and allows free markets to regulate the cost of care. In 2019, Medicare Payment Advisory Commission (MedPAC) supported changes in Congressional requirements for NPs to bill the Medicare program directly, removing incident to billing (The MedPAC Blog, 2019). This would allow Medicare to know who delivered the service helping to evaluate the accurate valuation of physician services and allow policy makers to evaluate the cost and quality of care delivered by NPs. Of interest, MedPAC estimated that over 40% of all NPs' evaluation and management office visits for established patients performed in physician's offices in 2016 were likely billed "incident to," making NP care invisible in Medicare data. In a recent study by Auerbach, Buerhaus, and Staiger (2020), it is projected that there will be two NPs for every five physicians by 2030. Implications for this projection are that NPs will largely fill the role of primary care providers, an area of practice where physician shortages are forecasted. Is not it time to allow market forces to work in favor of consumers?

Dr. Bauer's book makes a significant contribution to the understanding of purchasers of health care (governments and employers) and politicians who must work to provide health care to Americans. Heath (2017) points out that the shortage of physicians, in one survey, has resulted in average wait times of 24 days in many mid-sized and large metropolitan areas. Shorter appointment times for patients may be how some of this demand is managed now, but not recognizing the need for advanced practitioners to assume this increasing need for care would be short sighted.

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