Tuesday, March 9, 2010

Advanced Practice Nurses As A Solution to the Crisis in Primary Care

The Disease Management Care Blog welcomes colleague M’Lynda Owens, who is pursuing a PhD in nursing and has extensive experience in the health care industry. She makes an important point: if the market isn’t willing to support primary care and the physicians themselves are walking away from that specialty, why would anyone oppose the expansion of nurses in this field, especially when there is so much science that supports it? Given that point of view, she also offers up some recommendations for health care reform:

This nurse couldn’t help but respond to the provocative comment quoted in the DMCB's recent ‘Selected Quotes’ posting: "When asked about physicians that are reluctant to transform their practices into patient centered medical homes, Gordon Norman offered this astute solution: 'Fine, let the nurses do it.' The silence in the hall was telling."

I've watched the national conversation about health care reform and find the silence surrounding the role of non-physician primary care providers (PCPs) deafening. Advance practice nurses (APRNs) and physician assistants (PAs) have been serving with distinction as PCPs for more than 40 years. Numerous studies (for example here, here, here, here, here and here) have repeatedly demonstrated high clinical quality and patient satisfaction associated with APRNs. In addition to their clinical outcomes, they’re also trained to commit more time talking with and listening to patients during encounters and have an excellent record of patient safety in a wide variety of settings.

APRNs do not want to displace physicians. What they are willing to do is use their training to fill the growing gaps in health care coverage. Physician groups note with alarm that increasing numbers of medical students are not choosing careers in primary care. That may not be necessarily bad. The level of education and skill possessed by specialist physicians for highly acute and complex cases warrants extensive training and should be commensurately rewarded. But someone has to serve in primary care. So if physicians don't want the job, why not let the nurses do it?

As noted above, there is ample science that shows that it doesn't take physician training to manage many of the tasks involved in primary care access, including treating upper respiratory illness, conducting wellness exams, caring for minor trauma, providing institutional care in nursing homes and prisons, following normal pregnancy, treating stable chronic conditions, collaborating with disease management initiatives and addressing the myriad other routine reasons people seek first-contact medical care. In addition, APRNs are paid less than physicians – which helps with cost containment for these types of services. Last but not least, APRNs are willing to serve in rural and economically disadvantaged areas, where reimbursements are low. This is Disease Management 101. Other than the turf battles, why not support letting the nurses practice what they've been trained to do in an evidence-based manner?

To make this happen, the following need to be included right now in health reform:

1. Independent licensure and prescriptive privileges across the 50 States are necessary so that physicians are not statutorily saddled with "supervising" or "collaborating" with APRNs who can competently practice and prescribe medications independently in all but 12 states. An APRN, practicing within her (yes, 95% her) independent licensure, should not be statutorily forced to find a physician willing to take on the oversight of another's practice.

2. Insurers need to reconsider their unwillingness to independently empanel and reimburse APRNs.

3. While the educational roles of pharmaceutical companies are being reexamined, they should drop their reluctance to provide educational support and pharmaceutical samples to APRNs; they are not shadow providers;

4. Pharmacies should honor APRN prescriptions that are not co-signed by a physician.

5. We also need to continue to gather hard data on the safety and efficacy of APRN practice patterns, including their contribution to the care of populations with chronic illness

Why not support the nurses? For the sake of cost containment, access, quality, and disease management, it just makes sense.


Suzanne Drake PhD, APN-C said...

Thank you for posting this article. Advanced Practice Nurses have a proven record of safe care comparable to physicians over decades with the added advantage of superior patient satisfaction. They are less costly to the the Healthcare system to educate and employ, and have lower malpractice rates. It seems like a no-brainer, doesn't' it?

kennylin said...

Although I'm a family physician, I'm not opposed to the idea of nurse practitioners providing primary care, either within a primary care physician practice or independently. But I disagree that this is the solution to the primary care workforce crisis, for the simple reason that nurses (and PAs, for that matter) are just like doctors: they follow the money. As long as primary care is poorly paid relative to other medical specialties, we won't attract enough clinicians of any type to provide the access to primary care that will improve U.S. health outcomes.

Jaan Sidorov said...

And thank you Dr. Drake for reading it and leaving a comment. I may post my own opinion about this at some point, but the key thing is that physicians don't seem to want to do it and the APRNs seem more than willing to step up. It may be the market is going to decide this is a no-brainers.

kennylin makes a good point: I've heard that APRNs tend to want to practice in the suburbs and, with time, may find that the market-based salaries are inadequate. So, over the short run, APRNs may run toward this opportunity but over the long run end up leaving for other career paths due to the same issues facing the docs.

I've also read that the pipeline of APRNs is not near enough to meet projected need.

As for the lower professional liability insurance rates, don't worry: as your role increases, our friends in the trial bar will find APRNs are also an attractive target for alleged acts of malpractice. They follow the money too!