Can nurses fill doctor shortage?

The United States has too few doctors with millions more Americans in line to get health insurance.

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. [audio:22kgnurse.mp3]

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.