The Battle over Letting Nurse Practitioners Provide Primary Care
by Maggie Mahar
Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder. To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:
“An NP has mostly on the job training...they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor. “I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR...THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]
Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another “Fierce HealthCare” reader notes the commenter’s emphasis on just how brutal med school can be: “The anger reflected in the previous comments reveals not only the writers' ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians' control...Many older doctors' schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn't sufficient.”
The American Medical Association (AMA) represents many members of the old guard, and is intent on protecting the guild. In some statehouses, the Associated Press (AP) reports: “Doctors have shown up in white coats to testify against nurse practitioner bills. The AMA, which supported the national health care overhaul, says that a doctor should supervise an NP at all times and in all settings. Just because there is a doctor shortage, the AMA argues, is no reason to put nurses in charge and endanger patients.”
But others argue that Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science.
Who Are Nurse Practitioners?
This raises the question: just who are these nurse practitioners, and how skilled are they? Nurse Practitioners are registered nurses with a graduate degree, usually a masters, though by 2015, a doctorate, or a DNP, in nursing practice will be the standard for all graduating nurse practitioners, says Polly Bednash, executive director of the American Association of Colleges of Nursing.
The profession sprang up in the 1960s, partially in response to a shortage of primary care physicians in rural areas. This was the decade when doctors began to specialize. (With the passage of Medicare legislation in 1965, suddenly there was more money on the table to pay specialists, and at the same time, medical knowledge was advancing at a breathtaking rate. More and more physicians wanted to become part of the well-paid vanguard, on the cutting edge of medical science.)
Today, the share of medical students who choose primary care continues to drop. Health care reformers hope that the legislation will reverse the trend by providing better compensation for primary care physicians, and by offering generous scholarships and loan forgiveness to med students who choose primary care.
This should definitely help. But if we are going address the needs of a population where chronic illness is now a much greater problem than acute diseases, we desperately need more primary care providers. Today, Managed HealthCare Executive reports, “nurse practitioners are the only healthcare professionals” who are pursuing primary care in “increasing numbers.”
Although there are many NP specialties (such as acute care, gerontology, family health, neonatology, pediatrics and mental health), about 80% of NPs have chosen primary care.
We need health care providers who want to be on the front line of managing chronic disease. NPs don’t seem deterred by the relatively low pay. Wealth is relative: while NPs, like most professionals, would like raises, they are not comparing their incomes to the $450,000 that an orthopedic surgeon might bring home.
This may help explain why research shows that patient satisfaction is often higher among patients who see NPs. These days, many primary care docs are burned out— and if a doctor isn’t happy in his chosen profession, chances are his patients will sense his malaise.
Low morale among PCPs is understandable. As a post on the Yale Journal for Humanities in Medicine (YJHM) blog points out: “Compared to other physicians, primary care doctors are at the bottom of the social order in the medical hierarchy. They are also among the lowest paid despite the many time-consuming tasks such as filling out insurance forms, drug refills, nursing home and hospital documents that must be read and acted on. These are in addition to the many coordinating responsibilities that they perform for their patients.
“For most of these tasks, many primary care doctors are actually ‘over-qualified.’” YJHM continues. “Clearly, while they have taken on the role of health care ‘coordinators’ they have become more dependent on specialists to take care of the sickest patients. Their ‘scientific’ medical role has decreased while their ‘coordinating" role has increased. For many primary care physicians their medical training is of less importance in their new roles.
“It is wrong to insinuate that nurse practitioners do not have the medical training necessary to perform some and even many of the tasks that primary care doctors now perform,” the YJHM blog concludes.
Let me be clear: not all primary care doctors spend most of their time coordinating care and referring patients to specialists. In parts of the country where there are fewer specialists, PCPs do more of the work of diagnosis and treatment themselves. In addition, many primary care physicians work in large mutli-specialty practices where they are far less likely to be immersed in paperwork; often they are actively involved in teaching patients to manage their own chronic diseases. But it is true that the internist working solo or in a small private practice in many cities often finds himself/herself mediating care rather than providing care.
As for nurse practitioners, as they become a growing force in the medical profession, morale among them is rising. Twenty-three states now credential nurse practitioners as primary care providers, and given the legislation under consideration in states nationwide, that number is bound to grow. Nurse practitioners are feeling empowered. In 1990 there were 30,000 NPs in the U.S. Today there are 115,000 according to the American Academy of Nurse Practitioners (AANP). And they know that they can do everything a doctor does: take the patient’s clinical history, perform physical exams, diagnose disease, order and interpret laboratory radiographic and other diagnostic tests, and prescribe medications.
NPs can prescribe under their own signature in every state, although in four, including Florida and Alabama, they cannot prescribe controlled substances and narcotics. This can make pain management difficult.
While NPs Earn Less, They Spend More Time with Patients
Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85% of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60. If these nurses provide primary care, this “saves money for the Medicare program,” Jan Towers, PhD, director of health policy for the American Association of Nurse Practitioners (AANP) points out.
In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000.
Nurse practitioners also help rein in health care spending because they “advocate prevention and health promotion,” says Towers. “As a result, there are multiple studies that show lower rates of emergency room visits and a lower number of hospital days by patients.”
Going forward, I suspect that nurse practitioners will help run many of the new community clinics that reform legislation is funding. There, they will create the medical homes that newly insured low-income patients need, and help keep them out of ERs.
How will they do this? Research published in BMJ suggests that NPs spend more time with patients than doctors do, and simultaneously, cut costs. A study by Avorn and colleagues published in the Archives of Internal Medicine supports the thesis. The study used a sample of 501 physicians and 298 NPs who responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). The doctors and nurses were able to request additional information before recommending treatment. If they took an adequate history, the provider learned that the patient had ingested aspirin, coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the physician group was more likely to prescribe a medication without seeking the relevant history. NPs, in contrast, asked more questions, obtained a complete history, and were less likely to recommend prescription medications.
A 2004 study by Mundinger, Kane, and colleagues is now considered the most definitive research on the quality of NP care. It explored the outcomes of care in patients randomly assigned either to a physician or to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice had the same degree of independence as the physician: this made the study unique. After analyzing the services that patients used, and interviewing some 1,136 patients, the researchers determined that the health status of the NP patients and the physician patients were comparable at initial visits, 6 months, and 12 months. A follow-up study conducted two years later showed that patients confirmed continued comparable outcomes for the two groups of patients.
Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health rejects the argument that patients' health is put in jeopardy by nurse practitioners. “There's no evidence to support that,” Needleman told the AP. “Other studies have shown that nurse practitioners are better at listening to patients. And they make good decisions about when to refer patients to doctors for more specialized care.”
Nurse Practitioner midwives also receive high marks. They attend 10% of all births in the U.S., 96 percent of which are in hospitals. A number of studies of low-to-moderate-risk women giving birth show that after controlling for all social and health risk factors, the risk of infant death with a nurse-midwife is as much as 19 percent lower, neonatal mortality as much as 3 percent lower, and low-birth-weight infants up to percent fewer than with physician-delivered babies.
Other studies reveal lower rates of caesarian sections, as well as significantly fewer infant abrasions, perineal lacerations, and complications.
Researchers point out that it is possible that mothers who choose nurse practitioners to deliver their babies are healthier, or less inclined to want caesarians. But at least one study of high-risk mothers in an inner-city hospital suggested that midwives provide equally safe care in these more difficult cases.
Some NPs point out that they must do better. As Chicago nurse practitioner Amanda Cockrell explained to the AP: “We're constantly having to prove ourselves.”
Medical evidence that NPs offer as good or better care threatens some physicians. “They're really scared that we're going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” Dee Swanson, president of the American Academy of Nurse Practitioners, told ModernHealthcare.com earlier this month. “Let's face it: We have a crisis in primary care in this country, and it's an area that physicians have not been interested in, or there wouldn't be a shortage.”
Some Insurers Balk at Paying NPs; Reformers Reward Them
Despite all of the convincing data about the quality of care that NPs provide, “Acceptance by health plans varies across the country," the AANP’s Towers told Managed Care Executive. "Some are fully onboard in certain parts of the country. But in other sections, health plans are still hesitant and require strings that we believe are unnecessary.
"Then there are cases where you work very well with a company, but there is a merger with a company that hasn't worked with nurse practitioners,” Towers adds. "You have to start all over again."
In California, where insurance plans do not recognize nurse practitioners, the state’s more than 10,000 NPs are beyond frustrated. Although private insurers pay for the services offered by NPs, they do so as if the NP’s collaborating physician provided the care. (This may give the insurer an opportunity to pay less for the same care.)
In states where insurers shun NPs, patients are unable to name a nurse practitioner as their primary care provider, and this can lead to confusion. In addition, patients looking for a new primary care provider will only find physicians listed in their insurance company web sites and printed materials, even if well-trained nurse practitioners are available to serve them. (I can’t help but wonder, have these insurers succumbed to pressure from physician lobbies?)
When reform legislation kicks in and millions of formerly uninsured Americans begin to look for a PCP, many patients won’t be able to find a provider in California—unless the law changes.
This is one reason why the Josiah Macy Jr. Foundation, which funds programs designed to improve the education of health care professionals, recently recommended that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to lead multidisciplinary teams of primary-care providers. Dozens of health care organizations signed the report; the AMA was not among them, but the American College of Physicians was.
The Foundation’s proposal that nurse practitioners should manage health care organizations upsets some physicians. If NPs ran community clinics, they might supervise doctors, and even oversee programs training residents in primary care. "I would never want to see the nurse leading the team in a patient-centered medical home," Dr. James King, President of the American Academy of Family Physicians, said in 2008.
But the times are changing. Unlike some insurers, legislators who crafted health reform legislation seem to have paid attention to the research on quality. They are offering the same financial incentives to nurse practitioners that they offer to physicians:
• 10% bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners
• $50 million to nurse-managed health clinics that offer primary care to low-income patients.
• $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.
Moreover—and here’s the surprise—the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor's.
A Nurse’s Training-- It’s Not the Same
These days, nurse practitioners are spending more time in school. For example, on top of four years in nursing school, Chicago NP Amanda Cockrell spent another three years in a nurse practitioner program, much of it working with patients.
By 2015, the American Association of Colleges of Nursing will require its approximately 200 members to offer a Ph.D. Johns Hopkins already has rolled out a forward-looking graduate program for nurse practitioners that focuses on evidence-based medicine.
But even while nurse practitioners put more years into education, both supporters and critics agree: the training is not the same.
Daniel Lucky of Modesto, Calif., an NP adjunct nursing lecturer with University of Southern Indiana and adjunct faculty for Indiana State University, says that nurse practitioners take a different approach: "NP practice is based on the nursing model of care--not the medical model," he wrote in a commentary for the Evansville Courier Press. "Nursing teaches us that we should not reduce human beings to mere signs and symptoms, place a disease label on someone, give them a pill and send them off. As nurses we are trained to look at the entire patient from a holistic perspective and then, actively partner with the patient and family to not only correct problems, but also enhance optimal health. Nursing care places the patient--not the provider--as the central focal point.”
Critics put it differently: Texas physician Gary Floyd opposes giving nurse practitioners too much autonomy by arguing that “Nursing schools push a ‘care and comfort’ approach to giving care.” Floyd, who serves on the Texas Medical Association's Council on Legislation, contrasts training in “comfort and care” to “the scientific perspective of medical schools that teach about disease processes and bodily interactions.”
Here, I have to differ. As a patient, I’m a big fan of “comfort and care.” Not all diseases can be cured. If I were suffering from a curable disease, I would trust the vast majority of nurse practitioners to refer me to a specialist who might know how to conquer the disease. Otherwise, I would like to stick with the provider who focuses on talking to me, listening to me, comforting me, and making sure that I’m not in pain.
Health care reform means that we need to re-think medical school education. We don’t want to continue to train young doctors to fit into a system that we know is dysfunctional. Many medical educators suggest that we are making students take science courses that will be of little help when they actually practice medicine. Depending on his or her specialty, not all physicians need the same in-depth understanding of body chemistry or anatomy. Students are forced to memorize information that may well change as medical science evolves over the next five or ten years. When they are treating patients, they will look up the newest information on best practice, or the ideal dosage for patients who fit a particular medical profile,
In a 21st century medical school, many argue, students need more training in patient-centered medicine: how to educate patients so that they can collaborate in managing chronic diseases; how to share decision making with patients; how to manage pain; how to tailor end-of-life care with an eye to the individual patient’s greatest desires and worst fears.
Don Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid, defines patient-centered care in a way that sounds much closer to the nursing school model. Berwick argues that it’s all about asking the patient: “What do you want and need?" "What is your way?" "How am I doing at meeting your needs?" "How could I do that better?" "How can I help you?"
Isn’t that what nurses—and even doctors—once asked?