Nurse practitioners: Good for patients but a bitter pill for doctors

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One of the key selling points for the 2010 Affordable Care Act (ACA), or Obamacare, was that this landmark piece of legislation would lower runaway increases in health care spending. Now, evidence is mounting that despite the promises from ACA advocates, overall costs continue to escalate at an alarming rate.

While lawmakers and policy wonks continue to search for cost containment solutions, a turf battle is underway within the medical profession over the role of nurses with advanced degrees and education who can prescribe drugs, handle office check-ups and other tasks. In about half of all states, nurse practitioners are required to collaborate with or be supervised by physicians. Because more than 80 percent of nurse practitioners, as they are known, are certified in primary care they can provide a safe and cost effective solution to a looming shortage of family doctors, especially in rural and poor areas.

{mosads}The Veterans Affairs health system, another government health program with its own cost and quality problems, issued a proposal in May to expand the role of nurse practitioners by removing a rule that required them to work in teams supervised by a physician. The proposal’s open comment period recently received a record number of responses – 174,411 – double the amount of the previous record for a federal proposal, underscoring the vigor of the debate.

Cost and health care delivery issues are driving the changes. A Rand Corp study showed that using more nurse practitioners and physician assistants could save the Commonwealth of Massachusetts between $1.4 and $1.8 billion over a ten-year period. According to another Rand Corp. study, this one focused on Ohio, expanding the “scope of practice” regulations for nurse practitioners – allowing them to perform duties to the full extent of their training – would show vast improvement in the numbers of adults receiving routine care. “As many as an additional 1.5 million Ohio residents would potentially report better access to care,” the study concluded.

But doctors are digging in their heels. The American Association of Family Physicians, representing 125,500 family doctors and medical students, sharply criticized the VA proposal that would allow nurse practitioners to work independently.

“We believe that independent practice authority within the VA health system is not the answer,” said Dr. Daniel Wergin, association chairman. “Physicians offer an unmatched service to patients and, without their skills, patients’ safety would be at risk.”

Doctors and nurses are debating the VA proposal, and more widely the role of nurse practitioners, in OhioPennsylvania and Tennessee – among other places. A “turf war” has broken out in Tennessee, as a state appointed task force looks at expanding restrictions on nurse practitioners. “Doctors,” according to one report, “question whether nurse practitioners can offer the same level of care and have opposed efforts to expand the scope of treatment, preferring legislation to reinforce physician roles in primary care.”

What is not in dispute is a shortfall in primary or family care doctors, often the first people a person turns to when problems arise.

The federal government projects a shortage of 20,400 primary care physicians in 2020, “and other experts, too, have projected a large shortfall in the coming years,” according to a 2015 report from the Henry J. Kaiser Family Foundation.

It takes much less time to produce new NPs than new physicians – an average of six years of education and training, compared to 11 or 12 years for physicians, including education and residency. Citing federal statistics, the Kaiser report said federal health care analysts project a 30 percent increase in the supply of primary care nurse practitioners in the 2010-2020 period. The bottom line: Nurse practitioners and physician assistants, whose numbers are also projected to grow, “could potentially reduce the expected shortage of primary care providers in 2020 by about two-thirds.”

Let’s be clear, contrary to the hand wringing we’re hearing from physicians, expanding the scope of responsibilities for nurse practitioners is not a radical idea. In states that have allowed nurses practitioners full authority, they can work without an overseeing physician and meet the unmet needs of the poor, rural and other underserved communities. The reason we have studies showing positive health outcomes with nurse practitioners is that some states already grant them full authority.

To be sure, there will be cases when nurse practitioners need help from doctors. But why would we think these trained professionals would not contact the appropriate specialist on their own? Nurse practitioners will continue to be licensed by the state and will answer to their professional review boards.

Cost, access to care, and consumer choice all call for relaxing the regulations on nurse practitioners. Why aren’t we doing it?

Dr. David Mitchell is an associate professor of economics at the University of Central Arkansas and the director of the Arkansas Center for Research in Economics.

The views expressed by authors are their own and not the views of The Hill.


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