Can nurses fill doctor shortage?
Friday, July 2nd, 2010
By: Kerry Grens
kgrens@whyy.org
The United States has too few doctors with millions more Americans in line to get health insurance. Thanks to the federal overall, that need is only expected to grow. Training more physicians will take decades. But nurses say: they've got the solution all ready to go.
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Louise Diehl has a fairly unusual way of introducing herself.
Diehl: I'm a nurse practitioner, private practice, in Phillipsburg, New Jersey.
Unusual in that just a small minority of nurses work in their own private practice, independent from doctor's offices, hospitals or clinics. Diehl opened hers four years ago.
Diehl: I provide primary care, the same kind of care the primary care physicians provide.
Nurse practitioners like Diehl have at least a masters degree on top of their nursing degree, and the vast majority choose to practice in primary care. Diehl has about 1,000 patients in her database, and sees 20 to 50 of them each week.
Diehl: It's always nice to have your own job, be your own boss, and be the one in charge at taking care of patients.
If you're concerned about health care costs, here's something else that's nice:
Turton: We are about 11 percent less than other providers.
Tine Hansen-Turton is the executive director of the National Nursing Centers Consortium. Nurses earn less than doctors, and get reimbursed at lower rates from Medicare. Turton led a study recently that compared nurse-led to doctor-led clinics in the Philadelphia region.
Turton: We had lower emergency room utilization, lower hospitalization days, lower prescriptions, lower days in the hospital, we had more kids immunized on time.
Turton says the 150,000 nurse practitioners across the US could make a big dent in the need for primary care providers, if they are given more independence to practice solo. Yet, various factors inhibit nurses from following Diehl's lead and striking out on their own.
Schrand: What makes it hard is that you can't get credentialed and paid.
Sue Schrand is the executive director of the Pennsylvania Coalition of Nurse Practitioners. She says one of the biggest barriers for nurses who want to start practices is spotty reimbursement from insurers.
Schrand: Many nurse practitioners have been hesitant to hang out their own shingle because it's a loop that won't be met.
Insurers are beginning to catch on. Six years ago, just 20 percent of them reimbursed nurses for primary care; now it's about half. Independence Blue Cross has paid nurses for years – but only those in federally designated areas with severe doctor shortages. Richard Snyder is the Chief Medical Officer there.
Snyder: Recently we have started to entertain and contract with CRNP-led practices that are not serving those specific populations.
But it will take more than insurance companies to lure nurses out from doctor-led practices. Most states require nurses to have a collaborative agreement with a physician in order to get a license to prescribe medications. Nurse Louise Diehl says the regulation is outdated, and creates administrative blockades to seeing patients.
Diehl: I rarely ever talk to him. Occasionally I send an email. He trusts my care, my judgment. We don't interfere with each other's practices. He has a completely separate practice than me.
Donald Cinotti, the president of the Medical Society of New Jersey, sees this lack of supervision as troubling.
Cinotti: The question they're really asking is do you need a medical degree to practice medicine?
Cinotti says yes. Doctors have double or triple the number of years of training as a nurse.
He says nurses' independence from a doctor's supervision is not a prerequisite for having them play a bigger role in meeting the nation's primary care needs. What he thinks will expand nurses' abilities is a practice pyramid where nurses have some autonomy, but with most experienced person at the top directs the protocols and supervises care.
Cinotti: But I think that it's most important that at the top of that pyramid the person making the ultimate decisions on the protocols should be the highest trained person, which is the physician.
That argument has triumphed in most states for years, but it's slowly beginning to erode as more of them remove the requirement for doctor supervision. Nurses in New Jersey are launching a big lobbying push to make their state the next to grant them independence.
This was a very good story on nurse practitioners and their role in solving the primary care provider shortage but this story like most end with a physician (from a state that mandates colaberation or supervision of NPs by physicians) in opposition to allowing NPs to practice to their full scope of practice without that collaberation or supervision. Two points, first, NPs are trained differently than physicians but not less than physicians. Four years of undergraduate education, two to four years of graduate education (the NP profession is moving to the doctoral level) and frequently many years of working experence as a Registered Nurse before practicing as NPs. MDs had the same concerns about Doctors of Osteopathy (DOs) and now accept them as equals. Second, what matters most is patient outcomes from care provided by NPs. Please look at patient outcomes in states where NPs practice independently and do not require mandated physician collaberation or supervision. You will find that it is equal to or better than care provided by physicians. Physicians who oppose NP independent practice need to provide outcome data that demonstrates that people receive care from NPs have poorer outcomes than people who are cared for by physicians otherwise their argument is moot!
"NPs are trained differently than physicians but not less than physicians"
Right. So the 500 hours of clinical training of a NP is equivalent to the tens of thousands of hours of CLINICAL TRAINING required of physicians BEFORE they practice independently.
NP's provide a great service but their training is different and not equal to that of a medical doctor.
For 45 years Nurse Practitioners have been delivering quality healthcare and improving access to services. Numerous studies exist documenting our safety and efficacy. Lack of direct insurance reimbursement and antiquated "physician only" language in regulations restrict NPs from functioning to the full extent of their education and training.
All providers in the healthcare system collaborate to provide the best care for their clients. Thus, the need for a formal "collaborative agreement" is unnecessary and contributes nothing to patient care. With the rising cost of Healthcare and thousands of uninsured and underinsured Americans in need of care, It would be ideal if THE Healthcare community could come together and focus on what's important; IMPROVING ACCESS TO HEALTHCARE AND THE HEALTH OF ALL AMERICANS!
Nurse Practitioners have been practicing collaboratively, and in some states, independently for 40 years. It is only recently that the media has brought our profession to the forefront of attention. Physicians have not protested our ability to independently practice in rural areas, where they have not wanted to work. It is only recently, when the dire lack of primary care providers has been brought into the national spotlight, that "suddenly," we NPs must be supervised and "reined in."
Ridiculous! We are fully licensed and have the knowledge to know exactly when to refer to physicians…just as primary care physicians know when to refer to physician specialists. We do not practice in a vacuum…as some might suggest.
I believe that in order to care appropriately for all of our nation's citizens, all types of providers — physicians, nurse practitioners, physician assistants, etc. — must come together to collaborate. There are more than enough patients to go around.
We now need to remove the barriers that restrict our practice, whether it is getting credentialed, receiving equal pay for equal work (none of this 85% reimbursement nonsense), and public and professional acknowledgement for the work we do.
The fact is in Pennsylvania there is a need for more primary care providers and not enough doctors to fill the positions. If legislation is opposed to Nurse Practitioners practicing without supervision can we come up with a different way to allow collaboration without forcing the hands of physicians who don't want to collaborate? Lets work together as medical providers I thought we were supposed to be a team?
I practice in Mental Health, and PA has a serious Psychiatrist shortage, but the State and County governments are slow to respond to credentialing NPs to fill the need for prescribers. It is the consumers (patients) who are truly suffering; they are unable to get appointments within a reasonable amount of time. Clients are waiting many months to see a Psychiatrist, and are decompensating while waiting to be seen. I have never held myself up as being the educatinal equal to a physician, and I DO know what I do not know and refer clients to a physician when necessary.
I to am concerned. I am just a FNP student who will graduate in 2011. I have watched and listened to the NPs concerns as well as my own.We need to keep pushing forward to get the laws changed here in PA. It isn't that easy to get a collaborating physician, it can take many months as I have heard from the new graduates.I am glad we are drawing attention to this serious matter.
Thanks NPR for drawing attention to this important shift in Primary Care in our country.
The public needs a better understanding of how valuable NP are in the health care reform. I think above interview is balanced and informative.
Unfortunately PA continues to have a restrictive practice environment and the requirement for a collaborative agreement makes it very difficult for NPs to practice independently.