In anticipation of the numbers of primary care providers that will be needed in the near future, the Institute of Medicine recommended that advanced practice RNs be allowed to practice to the full extent of their education and training and be allowed to admit patients to hospitals, lead medical teams and medical homes, and be paid what physicians are paid for those services. As health insurance coverage expands under the Patient Protection and Affordable Care Act, the quality and cost of care will undergo stronger scrutiny. Does the expansion of NPs’ practice help or hinder efforts to provide primary care to millions more Americans? The answer depends on whom you ask.
Although NPs and primary care physicians agree with the notions that NPs should practice to the full extent of their education and training and that NPs can improve access to care, they strongly disagree on other issues. A recent study in the New England Journal of Medicine showed that although 82% of NPs think nurses should lead medical homes, only 17% of physicians think so. They're even more strongly split on reimbursement: 64% of NPs believe in equal pay for equal services, compared with 4% of physicians. When asked whether physicians give higher quality examinations, 66% of physicians said they did; 75% of NPs disagreed.
These results, from a survey of 467 NPs and 505 physicians, suggest that questions about fundamental roles need to be resolved if the delivery of health care is to improve.
“We were surprised by the level of disagreement, especially since primary care physicians and [NPs] have worked together for many years. We hope that all clinicians will strive to promote strong collaborative relationships within health care teams to achieve high-value patient care,” said study leader Karen Donelan, associate professor of medicine at Harvard Medical School in Boston, in comments to AJN.
Barriers to NP practice continue to fall. NPs currently practice without physician supervision in about a third of states. And recent legislation in several states has overturned obsolete laws, allowing NPs to expand their services:
* In June, Iowa's supreme court affirmed that NPs can safely supervise fluoroscopy (which they have done for years with no reports of injuries), reversing a lower district court ruling.
* NPs in Nevada started to independently prescribe medication without a physician's permission on July 1.
* Oregon's governor signed a bill in June that allows NPs to dispense some prescription drugs directly to patients, such as antibiotics for patients with urinary tract infections.
“We continue to see states remove barriers that prevent NPs from practicing to the full scope of their abilities in a timely, efficient way,” said Jan Towers, senior policy advisor for the American Association of Nurse Practitioners, which urges lawmakers in other states to follow the leads of Iowa, Oregon, and Nevada.
RNs and NPs alike, said Towers, “must step forward and provide leadership and guidance to remove barriers to [the] high-quality care that they provide. If we keep our eye on the patient, we can continue to do so.”
Changes brought about by health care reform should help to reveal the value of NPs to primary care. As Donelan pointed out, the expansion of electronic health records and direct billing for services provided by NPs will generate more data to evaluate the contributions of NPs and clinicians for policymakers.—Carol Potera
Donelan K, et al. N Engl J Med. 2013;368(20):1898–906