Midlevel No More

In today’s complex health care environment, the term “midlevel provider” has become increasingly obsolete.

Sept. 11, 2025 | | Written by Melanie A. Richburg, DNP, FNPC, RHCEOC, THIE Board Member & Underwriting Committee Chair

This article is sponsored by the Texas Hospital Insurance Exchange. This article does not necessarily speak to or reflect policy positions of THA.

In today’s complex health care environment, the term “midlevel provider” has become increasingly obsolete. For years, this label was used to describe nurse practitioners (NPs) and physician assistants (PAs), often as a convenient way to distinguish their roles from those of physicians. But as the responsibilities of advanced practice providers (APPs) continue to expand — and as they deliver care across a broader range of settings — it is clear that this terminology no longer reflects their clinical contributions or the way care is actually delivered in hospitals like ours.

APPs are not “midlevel.” They are highly trained, licensed professionals who serve on the front lines of patient care. Their scope of practice includes performing physical exams, diagnosing and managing acute and chronic conditions, ordering and interpreting diagnostic tests, and prescribing medications. Whether in primary care, emergency departments, inpatient units, or specialty clinics, APPs are central to delivering timely, high-quality, and cost-effective care — especially in the face of nationwide provider shortages and increasing patient complexity.

While NPs and PAs follow different educational pathways — NPs through nursing and PAs through the medical model — both roles require rigorous graduate-level training, board certification, and state licensure. Their roles often overlap in practice, and both bring unique value to multidisciplinary care teams. Importantly, while most PAs currently practice under some form of physician supervision, NPs can practice independently in the majority of U.S. states, contributing significantly to primary care access and chronic disease management.

Beyond clinical performance, recent data also dispels outdated concerns about malpractice risk associated with APPs. A comprehensive 17-year national analysis of malpractice payment reports offers valuable insight: while 37% of physicians were found to have made at least one malpractice payment during the study period, only 3.1% of PAs and 1.5% of advanced practice nurses (APNs) had done the same. Even more telling, the average payment amount for PAs was significantly lower than that for physicians.

These statistics are not only reassuring — they’re meaningful in today’s risk-aware health care climate. From a liability standpoint, the presence of APPs has not increased institutional risk. If anything, their involvement may improve system reliability. When liability events do occur, the underlying causes — such as documentation issues, communication breakdowns, or clinical judgment errors — are generally consistent across provider types. Importantly, there is no evidence that APPs contribute disproportionately to these events.

Moreover, the legal doctrine of respondent superior — which holds supervising physicians or institutions accountable for the actions of their employees — is frequently cited in malpractice discussions. Yet, as care teams become more collaborative and protocols are standardized, the distribution of responsibility becomes clearer and safer. In many systems, APPs enhance not only access and throughput but also compliance with evidence-based practices, quality measures, and early intervention — all of which contribute to patient safety and risk mitigation.

At our hospital, we witness daily the impact of our APP colleagues. They reduce time to treatment, support complex patient transitions, and serve as dedicated partners in delivering holistic, patient-centered care. Especially in high-volume or resource-constrained settings, their presence is indispensable.

As we continue to build care teams that are collaborative, innovative, and resilient, we must also evolve our language. Rather than using the term “midlevel provider,” which minimizes their role, let’s honor their training and impact by using the correct professional titles — nurse practitioner, physician assistant — or collectively, advanced practice provider.

Language shapes culture. By choosing accurate, respectful terminology, we promote a more inclusive, team-based model of care. Our patients benefit when every team member is empowered to contribute at the top of their license — and when every provider is recognized for the excellence they bring to the bedside.