When I wrote this blog, I had
suspicions that this was the case, but not enough information to
include it then. And did it happen – three days after my post.
Nurse Practitioners (NPs) are being targeted very heavily as medical
boards lobby state legislators to limit what NPs can do and not do.
If they continue to lobby for restrictions on NPs, you can almost
understand what patients are going to say when they have to wait to
see a doctor when NPs are available. It isn't going to be pretty
when they learn why the NP cannot see them and they must wait many
months to resolve a health problem. If you think emergency rooms
will pick up the slack, this may or may not happen
What are the issues? Nurse
practitioners are a type of advanced-practice registered nurse. They
are registered nurses who have also obtained a postgraduate nursing
degree, usually a master's degree. Doctor groups are claiming that
NPs will create safety concerns and must be restricted in their scope
of practice. At the state level, the battles are being waged by the
medical boards and the legislatures to determine the scope of
practice for non-physicians, including nurse practitioners. At the
federal level, the problems are on the NP's ability to be reimbursed
for the care they provide.
Because of the predicted shortage of
primary care as the population grows and as millions of people become
newly insured starting in 2014, one of the proposed solutions is to
expand the role of nurse practitioners in many more areas of the
country, and to allow them to provide a wider range of preventive and
acute health care services. Many areas of the country will be
without medical care if the physician shortage becomes as severe as
some are predicting. Rural areas will be particularly hard hit and
residents will face long commutes to see a doctor. Even some small
cities will have limited numbers of physicians.
The above map presently shows where
nurse practitioners are appreciated and valued and the states where
physicians in general don't want them. I am pleased that my state
still values them.
Some of the problems inherent in the
physician shortage will be the compromise of a broad range of medical
services. This will include initial valuation of new symptoms,
ongoing care for chronic diseases, and many of the preventive
services. If continued restrictions are placed on nurse
practitioners, the absence of availability of primary care will mean
increased mortality, increased emergency department visits (if these
remain available), and increased hospitalizations at hospitals
distant from the patient's residence.
I wish there were maps available to
depict the areas that the Health Resources and Services
Administration (HRSA) says that people are uninsured, isolated, or
medically vulnerable. The HRSA says it has identified roughly 5700
geographic areas containing 55 million residents as being in primary
care health professional shortage areas. To satisfy the target ratio
of one primary care practitioner for every 2000 residents, more than
15,000 additional practitioners would be required. Primary care
shortages will increase if the current trend continues.
For the last decade at least, there has
been less medical graduates entering the primary care arena. The pay
for specialists is the biggest reason for the decline in primary
care. Some policy makers are urging that there be pay equality to
bring more physicians into primary care. They are suggesting loan
forgiveness programs for physicians who practice in under served
areas.
What many physicians are unhappy about
is the increasing research that clearly demonstrates that patients
want primary care and this is more important that who is providing
these services. A careful review of 26 studies published since 2000
found that health status, treatment practices, and prescribing were
consistent between nurse practitioners and physicians. Two other
factors that are important are – patients say they have higher
levels of satisfaction with their care from NPs, and NPs have a
better reputation than physicians when evaluating patient follow up,
time spent in consultations, and other measures. I don't agree with
this, but it may be part of the equation to fill in the gaps in
primary care. “Nurse-led clinics may
provide care in under served areas or meet the demand for more
convenient care by providing a limited number of low-intensity,
commonly needed services, in locations such as retail stores.”
Many advocates say that changes in
federal and state laws need to be made to remove barriers to the
advancement of nurse practitioners. However, many physician groups,
chief among them, the American Medical Association, assert that
encouraging patients to see nurse practitioners rather than primary
care physicians may put patients' health at risk. This assertion is
not supported by evidence and even the Institute of Medicine (IOM) is
speaking out in favor of allowing nurse practitioners to fill the gap
being created by the primary care physician shortage.
“The IOM
recommended specifically that state legislatures reform
scope-of-practice laws and regulations to conform to the National
Council of State Boards of Nursing Model Nursing Practice Act and
Model Nursing Administrative Rules, which outline scopes of practice
for advanced-practice registered nurses. It further recommended that
state legislatures require fee-for-service plans within the state to
similarly cover nurse practitioner services. At the federal level,
the IOM recommended that the Federal Trade Commission identify state
regulations related to advanced-practice nursing that have an
anticompetitive effect without contributing to the health and safety
of the public, and that states be urged to change such policies.”
“The IOM
recommended that Congress change the Medicare law to make coverage of
nurse practitioner services consistent with coverage of physician
services. It further recommended that the Centers for Medicare and
Medicaid Services clarify that hospitals participating in the
Medicare program must allow nurse practitioners to have clinical and
admitting privileges and to be eligible to be on the medical staff.
The IOM also endorsed the notion that the federal government should
require plans participating in the Federal Employee Health Benefits
Program to cover services provided by nurse practitioners operating
within state laws.”
Whether the Institute of Medicine's
recommendations will be enough to tip the scales for nurse
practitioners, at lease members of state legislatures around the
country have something to support changes and no longer have to
listen entirely to self-serving physicians.
