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Author's Response to Letter to the Editor

Christin Giordano McAuliffeChristin Giordano McAuliffe, MD, is a board-certified nephrologist in Nashville, TN, at Nephrology Associates, a practice that incorporates both nurse practitioners and physician assistants in the care of patients.

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I am grateful to Ms. Ness and Mr. Juergensen for their reply to my article, “Use of Non-Physician Providers in the Nephrology Workforce Needs Careful Consideration and Urgent Attention,” published in this year's September edition of Kidney News. They raise the important issue of balancing financial interests with the ethical practice of medicine. The practice of ethical medicine and finance are two separate, often conflicting, domains of modern health care that may fail to overlap when incentives for sound clinical practice and ethical billing are misaligned with corporate goals of maximizing profit and seeking highest-level billing for each encounter.

To maximize profits, corporations are increasingly using non-physician providers with supervision models created by executives and scope-of-practice guidelines created through lobbying rather than clinical evidence. Physician assistants working in nephrology typically earn approximately half the salary of their physician colleagues and can bill 85% to 100% of physician fees, depending on state laws. Thus, there is a strong incentive for corporations to hire them. This cost savings is not extended to patients in the form of lower out-of-pocket costs. Rather, it is appreciated as profit into corporate coffers. “Legal” and “ethical” are a mismatch where quality of care is paramount. A Cochrane Review (1) found the studies presented by Ms. Ness and Mr. Juergensen woefully inadequate, and another, more recent study (2) found that physician-led care contributed to better patient outcomes and lower health care costs.

A fully trained physician assistant has significantly fewer training hours than a fully trained physician, and the content of that training is vastly different. As a former physician assistant myself, I appreciate this difference. I earned my medical degree and completed 5 years of postgraduate training to provide expert nephrology care. Properly supervised NPPs improve patient access and I invite all non-physician providers to join me in advocating for the highest quality and safest care for patients, rather than the interests of any health care professional or corporation.

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