Advancing Healthcare: History, Trends, and Considerations for APPs

In the 1950s, when the Baby Boom and wartime healthcare needs expanded patient panels and strained hospitals’ resources, medical training programs began looking for solutions to meet the growing need for primary- and criticalcare providers.

As the Vietnam War reached its midpoint, military personnel providing overseas medical care offered a potential solution to the provider shortage, says Paul Fry, PA-C, director of ambulatory services at California’s Lompoc Health.

“During the Vietnam War, there often weren't physicians available to treat overseas personnel, so Navy Corpsmen and Army Medics were doing a lot of the thought work, diagnostics, and treatment,” Fry says. “These individuals gained valuable skills and knowledge that, at the time, they couldn’t use as civilians.”

In response, Duke University launched its Physician Assistant (PA) training curriculum in 1965, enrolling four Navy Corpsmen in its inaugural class. The same year, the University of Colorado enrolled the first prospective Nurse Practitioners (NPs) in its new training program. Similar programs quickly followed suit, springing up at the University of Washington and Baylor University. In the 1990s, Frontier Nursing University, the first U.S. school to provide graduate nursing education, enrolled its first Community-based Family Nurse Practitioner (CFNP) program to train nurses to provide primary care. Soon after, the school offered a graduate degree in nurse-midwifery. 

“APPs tend to be hard-working, thorough, and hesitant to complain,” he notes. But this comes with its downside. “By virtue of being non-physician practitioners, they can also be insecure and become isolated if they're not given the opportunity to build confidence.”

Another trend may be negative: that of increasingly rigorous entry-level degree requirements for APPs. While some APP licenses used to require a bachelor’s degree, graduate-level education is now standard, with doctoral programs becoming more common. This may discourage otherwise qualified people with relevant experience from pursuing APP certification.

“Interdependence between physicians and APPs creates the collaboration that reduces risk. If organizations want to decrease risk, they need physicians willing to take on the supervisory role.”


“We want to guard against academic inflation for entry requirements, so we don’t price ourselves out of the market and become unavailable to the rural communities we serve,” says Fry. “It’s important to maintain our focus on underserved communities.”

As APPs grow their ranks and reputation, he notes, there’s also a push for greater independence for some, while others wish to retain their interdependence on supervising physicians. This tension is shown by disparities in Medicare reimbursement rates for different APPs: some are reimbursed at 100 percent, while PAs are reimbursed at 85 percent unless a physician is involved in the care.

A multi-level reimbursement plan that encourages physician-APP collaboration is actually something that should be protected, says Fry, because it supports important communication between members of healthcare teams. 

“Reimbursing PAs at 100 percent when a physician is involved in care helps drive the idea that we need to remain interdependent,” he says.

This collaboration helps address another prominent consideration for APPs and their colleagues: concerns about medical liability. In some cases, these concerns might impact hiring decisions or discourage close collaboration between APPs and physicians. But strong working relationships between members of healthcare teams creates the best outcomes for providers and patients. 

“Personally, I want to protect interdependence with the supervising physician,” Fry says. “Interdependence between physicians and APPs creates the collaboration that reduces risk. If organizations want to decrease risk, they need physicians willing to take on the supervisory role. That means not just signing charts, but developing a relationship over the years and helping an APP grow their skills, experience, and judgment."

American Academy of PAs, Duke University, New England Journal of Medicine, Frontier Nursing University, American College of Nurse-Midwives