Mundinger, Mary O. RN, DrPH
The debate about the role advanced practice nurses (APNs) will play in tomorrow's health care system is best understood by looking at the history of these practitioners and by analyzing an inadequately understood profession. APNs are nurses with graduate degrees in an area of clinical specialty. Midwives and nurse anesthetists were among the first to have distinctive educational and certification programs, beginning in the 1930s and 1940s. Advanced practice nurses in primary care—called nurse practitioners—began in 1965.
Nursing is historically a caring profession, inextricably linked with medicine. Since the profession's beginning, the physician/nurse gender distinction has been profound, reflecting men's and women's traditional social roles. In addition, medicine has a standardized and lengthy educational process, while nursing still has a variable educational process and for years was limited to the highly supervised hospital site. The gender and education differences resulted in far less independence for nurses. While nursing is the older of the two professions (with midwifery as much as a century older), medicine is more mature in its current configuration, having carved out its independence early and well. Florence Nightingale, in her brilliant two years of service on the battlefields of Crimea 150 years ago, became the first health outcomes researcher, using sophisticated biostatistical methods to showcase how nursing's prevention-oriented practices dramatically reduced infection and thus mortality. When she innocently instituted “doctors' orders” for her nurses, with the aim of documenting the full scope of activities of which nurses were capable, she instead delivered a coup de grace, making nurses appear to be dependent on physicians for their interventions.
The public's view of how nurses and doctors interact has not changed much since the early, formative years of physician—nurse relationships, but in reality enormous change has occurred. One hundred years ago most nurses were educated in hospital-based schools and prepared for hospital careers. The only real alternative was public health nursing: visiting new mothers and their infants at home or providing basic illness care to poor patients in public clinics. Early in the 20th century, nursing education began to enter the mainstream university setting, joining medicine as a learned profession, but often leaving hospitals—and physicians—disgruntled by the erosion of the student workforce, which had worked 40 or more hours a week and had been so instrumental in providing good patient care. Today, some four generations later, the poignant cry for nursing students to “return to the bedside” continues to echo in even the most intellectually advanced medical schools. The students are still in hospitals but not as full-time workers, and not necessarily preparing for bedside nursing careers.
By 1930, nursing schools had begun to establish doctoral degrees in research and education, and by 1965, a nurse with a doctorate (Lee Ford) and a physician (Henry Silver) had developed a new education program to teach public health nurses expanded skills—including advanced physical assessment and pathophysiology—to detect and monitor illness in their home-bound patients. They called this new graduate a nurse practitioner, or NP. NPs are essentially APNs who focus on primary care.
Nurse practitioners rapidly became one of the nation's primary care resources. They had traditional nursing skills from their baccalaureate-degree programs—including care of critically ill patients, leadership abilities to oversee a hospital nursing staff, public health experience in providing care to patients in community settings, and extensive education in managing patients' responses to their illnesses, including helping to reduce the risks of disease recurrence, strengthening healthy behaviors, and teaching patients how to believe in and comply with often complex and onerous medical regiments. It was an easy leap from better public health practice to primary care, especially in the early 1970s, when the Nixon price controls hit hospitals, more patients were being cared for in ambulatory settings, and the increasing needs of the underinsured were becoming evident. NPs appeared to be a great resource for primary care delivery to the poorer members of society. In the next several years NP education grew to also include expanded pharmaceutical prescribing and management training, differential diagnostic skills, more in-depth biophysical knowledge of illness, and additional training in ordering and interpreting basic lab and radiology tests.
It is no coincidence that NPs and Medicare and Medicaid legislation arrived the same year. There was an overwhelming national concern about access to health care and finding the resources to provide it to everyone. NPs were welcome indeed. In 1972, only seven years after the NP arrived on the health care scene, Medicare authorized payment to NPs for providing primary care to the rural undeserved elderly. Medicaid authorized NPs for primary care reimbursement on a state-by-state basis, and finally in 1990 required every state to reimburse NPs for family and pediatric primary care.
As hospital positions compatible with the more sophisticated training nurses were receiving declined, nursing schools began to turn their attention to advanced practice training programs. Primary care programs flourished in the 1980s, and by then there were as many as 20 different graduate-level specialities, including those in nurse midwifery, nurse anesthesia, psych/mental health, neonatal care, and oncology. From 1992 to 1995, the number of programs preparing APNs doubled. Today approximately 8,000 nurses in these specialties graduate annually. Until only a few years ago, most APNs practiced with undeserved populations, in part because that was where the reimbursement was. They were essentially practicing under the radar screen of physicians and commercial insurers.
Late in the 1990s this began to change. The quality and medical effectiveness of NPs had been evaluated (with no deficits identified) for two decades. The nurses and their patients knew that the primary care they delivered was very good. Managed care, the new euphemism for the way insurers paid for care, was causing concern and even alarm among the public and among physicians. Reduced payment was resulting in fewer and shorter patient visits, and physicians found they had to see more patients to make the same income. They blamed managed care for the shorter visits, when in fact it was their own wish to maximize income that led to reduced time with patients. Many physicians rethought their commitment to primary care careers when they saw the huge differential between fees paid to specialists and those paid to generalists, a differential made worse by the greater time burden that generalist practice usually entails. The country began to worry about a primary care deficit and began using financial subsidies to bring more medical students into primary care. In the midst of this focus on physician career choice, nursing was quietly adding thousands of individuals to the primary care ranks, and they were getting paid for their services.
The last barrier to APNs' advancement was commercial insurers. In the 1990s, as physicians fled primary care and as managed care began to take real political heat from the public for restraining choice, the opportunity was ripe for NPs' patients to seek reimbursement from commercial insurers. In 1997 Columbia University's nursing faculty became the first group practice to achieve reimbursement contracts with commercial insurers, at fee parity with primary care physicians. The Columbia nursing faculty were also the first to be evaluated in a full-scale randomized trial, which measured health outcomes, as well as the process of care, of NPs' patients compared with the health outcomes of the patients of primary care physicians; the study was reported in JAMA in 2000.1
DIFFERENT STYLES, DIFFERENT OUTCOMES
Commercial insurers were willing to credential and reimburse NPs for primary care if there were strong indicators of quality, embedded in education and experience. They were looking for a high-quality cohort of providers who could carry out the same interventions and accomplish the same outcomes as primary care physicians could. The three-decade march of NPs' advancement, from inception in 1965 to commercial insurer recognition in 1997, was based almost exclusively on demonstrating sameness of practice processes and outcomes. While many careful observers of NP practice recognized that NPs offered a different style of practice—some citing the “feminine” aspects of nursing, involving caring, nurturing, support, teaching, accessible personalities, etc., no one was making the connection between this different style of practice and the different outcomes from those achieved by primary care physicians. It is this critical point on which NPs' survival will rest in the future.
Primary care training, whether for NPs or for physicians, relies on a two- to three-year program of study following professional licensure (RN or MD). The training adds experience and formal education in diagnosing, treating, managing, and referring initially undetected acute or chronic illnesses. Physicians do this from a two-year background of in-depth biophysical sciences and month-long rotations among the various medical specialties. Nurses undertake similar primary care training from a background of hospital, community, and home-based care of individuals, with indepth sciences of health education, communication, risk reduction, and health promotion, and a broad introduction to disease and medical management strategies. NPs and MDs leave primary care training with different perspectives and different constellations of skills, although the primary care knowledge and training may be quite similar. The resulting practice styles can be very different, and in the context of emerging need and demand in U.S. health care, each serves a uniquely different purpose.
Conventional graduate programs in advanced practice nursing focus education on preparing a clinician for practice in limited encounters that are usually site-specific. For an NP, the primary care APN, education is focused on care in an ambulatory site, such as a clinic or private office. Today payers and patients recognize that primary care encounters take place in many settings in addition to the traditional office. The involvement of primary care providers (assessment, monitoring, and interventions) when their patients are undergoing emergency room evaluation or during hospitalizations has value and benefit, both for health outcomes and for cost containment. A patient in rehabilitation or a long-term care setting also needs a provider who has a primary care perspective and skills, not only to help resolve a current condition, but to concurrently protect and advance the full health needs of the patient. Payers already reimburse NPs for services beyond the ambulatory site; the Balanced Budget Act of 1997 authorized direct payment to NPs for all Medicare Part B services regardless of site of care.
Nursing education for cross-site, fully accountable care, however, is informal at this time and is not standardized. Building on the model of full-scope primary care that the Columbia University School of Nursing has developed and evaluated over the past nine years, the Columbia faculty have crafted a plan to formalize this practice in a new degree: the Doctor of Nursing Practice, or DrNP.
Three national and international conferences have been held over the past two years—first, to reach consensus on clear and uniform standards of advanced clinical preparation; second, to establish significant interest among academic nursing leaders and their national organizations to work toward such a standard; and third, to ensure that medical and health policy leaders understand and endorse the proposed doctoral-practice degree for nurses who meet the standard. While the basics of advanced primary care delivered by NPs—care delivered with full accountability in any site where a patient needs such services—may be indistinguishable from primary care delivered by physicians, nursing care is always distinguished by its attention to illness prevention, to health promotion, and to teaching effective self-care.
The future success of advanced practice nursing—whether in primary care or in any of the medical specialties where APNs now practice—is dependent on sustaining and clarifying not the sameness of but the difference between care given by physicians and care given by APNs, and on building the structure in which both physicians and APNs can provide their valued services. This is not simply about APNs' surviving, but about whether the benefits of their differentiated services will survive. Physicians and APNs each offer a distinct set of services and outcomes that will enrich health care in the years to come. To focus wrongly and shortsightedly on substitutional issues and the samenesses of these services is to miss the more important and fundamental issue: How can we build a system where patients thrive because both of these paradigms of care are equally accessible and available?
SEEKING A NON-COMPETITIVE, RICHER FUTURE
There are five basic questions that must be answered in order to reach the preferred, non-competitive future in which physicians and APNs function together effectively:
1. What is the differentiated practice of APNs (defined below) and how does it yield different outcomes?
2. Is there a market for this style of practice?
3. Will it compete with the kind of primary care provided by physicians?
4. Won't APNs simply “follow the money” and change their style to be more like that of physicians?
5. Is differentiated practice of APNs valid only in primary care settings?
Differentiated practice is primary care that attends to the patient's preference when possible and to engagement with the patient always, and that fosters the patient's abilities to follow a new regimen through the strategies of risk reduction, health promotion, health education, and counseling. APN primary care also involves assessment of community and home-environment resources in tailoring an intervention, a sustained perspective of overall health protection and advancement, careful use of the family as a precious and nonrenewable resource, and accessible responsive encounters. While the basics of medical primary care—diagnosis and treatment of undetected or chronic illness—are inherent in every primary care practice, the different outcome more common with APN care is a patient who is (1) more informed, more invested, and therefore more cooperative about care; (2) more empowered in self-care aimed toward illness resolution or health advancement; and (3) more confident that his or her total health parameters are being addressed on a routine basis. This leads to health outcomes that are different from those achieved by conventional symptom or disease resolution. While many physicians address their patients in this comprehensive way, this style is more routinely and reliably delivered by APNs, and APNs are the only clinicians trained scientifically to provide this scope of engagement and care.
Certainly there is a market for this style of primary care, but only if two things happen: (1) the public knows how to access an NP, and (2) the payers pay for such care. Today the payers reimburse for medically based primary care, and they reimburse NPs when they are assured of high-quality training and experience, and when they have beneficiaries who want this choice of provider. Payers are beginning to understand that while NPs deserve equity on a fee-for-service basis, the clinician who practices this way has far less opportunity to earn a yearly income equal to that of clinicians whose visits are shorter and therefore more profitable. This may be one reason that physicians have not adopted this kind of care model.
Differentiated practice has a growing market in today's health care system for several reasons. Patients already expect to assume a more empowered and authoritative role in their health care. They want their questions answered, they want choice, and they want power in joint decision making. Similarly, they are more fitness- and health-oriented, as well as being riveted on making sure they get well when they fall ill. Many aspire to higher levels of health even without evidence of illness or disease, and it is highly likely that with the advent of individual genomic mapping everyone will aspire to some new level of risk reduction in the future. Longer life spans, better medical care of previously fatal diseases, and the emergence of an ever-increasing burden of chronic illnesses—all point toward primary care that will require more comprehensive skills. These aspects of care draw on nursing expertise and take time, lots of time. NPs will fill the need.
This differentiated NP practice will not substitute for or even seriously compete with physician-provided primary care. Since the 1976 Mendenhall Report, we have known that specialists already provide significant amounts of primary care to their patients. Today, patients who are vulnerable and frail from unresolved or past life-threatening illnesses may be best served by their specialists, who know them best and who can distinguish rare or nuanced symptoms that could be related to their major diseases. Physicians in general enter their profession to diagnose and treat illness and disease. They usually do not seek a career in which they are patient guide and teacher as well. While they could learn the nursing paradigm, they have made other decisions about how they want to practice. Nurses, too, have made deliberate decisions; often they have selected the nursing profession because of the very aspects that distinguish it from medicine. And, increasingly, those who enter nursing at its most independent levels of practice are intellectually and academically similar to those who choose medicine.
Since smart, informed individuals choose to become APNs, why won't they “follow the money” and simply use nursing as a different path to practice like physicians, with a targeted number of shorter patient visits, which allow higher incomes and more prestige? Some may, but most choose the highly engaged patient care process knowingly, and do so because it gives them deep satisfaction and rewards that are as important as a higher salary. A second answer to the “medicine equals more money” issue is that payers will become ever more responsive to paying for services that are cost-effective. If APNs' care saves money (higher levels of health, less use of expensive care, more effective self-care, etc.), it is entirely possible that they will reach income parity by having a higher fee-for-service reimbursement. We are entering a system of payment that will more closely reflect value, and evidence of a given style of practice that reduces cost will be very attractive to those who pay for care, either insurers or the patients themselves.
Primary care by nurses is distinguished by a health perspective that recognizes the whole person. This same generalist approach distinguishes APNs wherever they provide their services. For example, 26 of the Columbia APN faculty—all with primary care educations—practice full time in specialty-oriented medical departments at Columbia. These clinicians bring to those practices an approach and attention to aspects of patient care not provided by the physicians. Each of these nurses is credentialled for full prescriptive authority and for admitting and co-management services in the medical center hospital. This allows them the access (and reimbursement potential) to see patients—usually follow-up patients in the ambulatory setting, but also inpatients who are stabilizing after surgery or extensive medical care. They provide discharge education for patients and their families, make home visits when necessary to smooth transition from hospital to home, plan for and arrange home-based resources, and may decide when a patient is ready and supported for discharge. In the office setting, these nurses may provide medically oriented services, such as follow-up monitoring, changes of medications or other therapies, or the perspective of health protection for aspects of the patient's condition other than the specific one being treated by the specialist. Patients who have chronic diseases (such as hypertension, asthma, diabetes, or cardiovascular or neurologic disorders) are in need of constant monitoring and assessment during any acute episode requiring focused medical intervention, but especially if they are being treated for another unrelated condition. APNs offer that critical continuity and protection.
An adversarial relationship between physicians and NPs would be fostered by arguing that NPs, with similar outcomes and lower costs, could substitute for physicians in primary care. This is not likely to occur. If the argument were “no difference, same cost,” the long-established physician standard would constrain advanced practice nursing's success. An argument of equal pay for equal work (outcomes) would change the physician/NP dynamic. The reality of different process and expanded outcomes with an NP, however, allows patients to choose depending on their needs and interests. The different perspective and skills APNs bring to patient care suggest that there is a value-added aspect, one which in many cases will be more cost-effective, and which—in partnership with physician care—offers broader benefit than with either provider alone.
If these potential partnerships are the most cost-effective, offer the broadest benefit, and perhaps achieve the lowest aggregate cost, why not just forget the “independent” status of APNs and have members of the two professions form teams? That sounds suspiciously like the medically dominated system that has been in place for decades. When physicians call the shots alone, they are less likely to recognize and honor the unique aspects of nursing practice that they do not have in their own skill set. They may not value those skills and may not allow those skills equal—and sometimes priority—status in patient treatment plans. Only when APNs have the same independence, the same access to patients, and an equal voice in the treatment plan can patients reliably receive all the care they need, when they need it, in the ways that are most beneficial.
“Team” suggests a leader, and a hierarchical structure. It may be that the most effective coalition of APNs and MDs in the future is more akin to partnerships—equal-authority partnerships—with the patient as the third and stabilizing component. In order to build these promising partnerships, the APNs must have the substance of training and knowledge and clinical expertise to assume full and equal authority with physicians, and an identity that signals to everyone the level of valid authority being exercised. The DrNP degree can accomplish both and can distinguish for all of the constituents—patients, physicians, and payers—which nurses have earned this place of distinctive service in a health care system that increasingly values quality and outcomes.
Academic medicine must play a central role in the advancement of the DrNP. The degree programs should first be instituted where the most highly educated physicians and nurses can design and establish this new role. If the ultimate goal is for members of the two professions to work as peers, it will be most fully attained if the training is also a joint effort. Academic medicine and nursing reside together at academic health centers, where research and careful clinical evaluations are inextricably linked with clinical care. This is the environment in which an advanced clinical role for nursing should be developed. The time is right for this promising idea to become part of our joint professional efforts; it is our best hope of bringing the values of nursing and medicine together for our patients.