November 9, 2012

Are Doctors Lobbying Themselves Out into the Cold?

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

This is some startling facts you need to be aware of and understand about the positions of our medical professionals. Currently there are 18 states and the District of Columbia that allow nurse practitioners to diagnose and treat patients and prescribe medications without a doctor's involvement. On the other side, 32 states require a physician's involvement to diagnosis and treat or prescribe medications, or both. The National Conference of State Legislatures reports that as of February 2012, 245 bills had been introduced in various state legislatures related to changing scopes of practice. About 50 of these bills would affect nurses, including advanced-practice nurses. It looks like our physicians are out to hamstring their own profession, by shutting out the people that could come to their assistance.

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.