Why Nurses Need More Authority

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Allowing nurses to act as primary-care providers will increase coverage and lower health-care costs. So why is there so much opposition from physicians?  

nurse 2-bvody.jpgReuters

Think it takes a long time to get an appointment with a primary care provider now? Brace yourself: it will likely only get worse. We're facing a severe shortage of primary care physicians in the nation. The Association of American Medical Colleges predicts a shortfall of 29,800 primary care physicians by 2015, and 65,800 by 2025, mainly because of the anticipated increase in demand for services from the Affordable Care Act (ACA), deterrents to entering the field, such as relatively lower incomes, and growth in the general population and specifically growth in the elderly population. Should the ACA pass muster with the Supreme Court next month, an additional 30 to 33 million previously uninsured Americans will be covered -- and even if ACA is not implemented in full, and in the end merely expands Medicaid, it will add 17 million to the insured ranks by 2020.

One of the best ways to alleviate this shortage is to expand the scope of practice for advanced practice registered nurses (APRNs), well-trained registered nurses with specialized qualifications who can make diagnoses, order tests and referrals, and write prescriptions. APRNs could provide a variety of services that primary care physicians now provide.

The definitive word on medical practice in America -- the highly respected and impartial Institute of Medicine (IOM) of the National Academy of Sciences -- has weighed in on this idea of allowing APRNs to do more, in a landmark 2010 report "The Future of Nursing." The IOM conducted an exhaustive review of all the available studies of the efficacy and safety of care provided by APRNs and concluded that properly trained APRNs can independently provide core primary care services as effectively as physicians. They can provide wellness and preventive care services, diagnose and manage common, uncomplicated acute illnesses, and help patients manage chronic diseases such as diabetes. In its report, the National Academy of Sciences recommended that "[a]dvanced practice registered nurses should be able to practice to the full extent of their education and training."

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But despite an urgent need and clear evidence that APRNs can complement and extend primary care providers' roles -- without sacrificing quality of care -- nurses are only permitted to practice independently to the full extent of their training and competence in 16 states and the District of Columbia. The remaining states impose regulatory barriers that limit their scope of practice. These barriers should and can be removed.

But the turf wars of organized medicine are preventing progress. The American Medical Association, the American Osteopathic Association, the American Academy of Pediatrics, and the American Academy of Family Physicians all oppose expanding the scope of nurse-practitioner responsibilities, despite the IOM report and recent research demonstrating that an expanded scope of practice for APRNs has no impact on primary care physician income.

In Colorado, where there are far too few anesthesiologists available for rural and critical access hospitals, the state's medical and anesthesiologists societies sued to overturn former Governor Bill Ritter's 2010 decision to allow Certified Registered Nurse Anesthetists (CRNAs) to provide anesthesia and pain management care in these hospitals. Instead, they prefer to make people travel hundreds of miles out of their communities to have a procedure that a CRNA is licensed and trained to carry out. They are also apparently fine with hospitals being forced to close as a result of a lack of anesthesiologists. This is a classic example of doctor-centric care trumping patient-centric care.

Apparently the physician organizations are threatened by some mix of concerns about lost income and their traditional position as "captain of the ship." Those opposed to expanding the scope of nurses' practice also argue that physicians with more years of training under their belts must necessarily know more than an APRN ever could. Of course they know more, but it is well established that they do not know more about providing the core elements of basic primary care.

And why primary care physicians -- already overburdened and overworked -- wouldn't want some support with routine care and services is puzzling. Allowing well-trained APRNs to handle routine care frees up physicians focus on diagnostic dilemmas and more complex management issues while dramatically reducing waiting times for care.

Expanding nursing scope of practice not only can help fill the gap in primary care providers, but it can save money as well. RAND estimates that in Massachusetts, using nurse practitioners to their full capacity could save the state between $4.2 and $8.4 billion over ten years. Other studies find sizable savings from care provided by nurses in clinics in retail pharmacies. In these cases, APRNs have the authority to diagnose, treat, and prescribe medications, among other services. Also, tapping nursing's potential is the fastest and least expensive way to meet growing demand for primary care. Nurses can be trained faster and for a lot less than medical school costs. Between three and 12 nurses can be educated for the price of one doctor.

There is hope. Employers and patients are beginning to clamor for progress in this area and the turf wars may lose steam as we move away from fee-for-service and toward accountable care organizations, in which a team of providers takes responsibility for the well-being of a population in return for global rather than provider-specific payments. The Federal Trade Commission may provide a further nudge. It has weighed in on a handful of states' efforts to restrict nursing's scope, finding cause for anti-competitive practices and, in some cases, evidence that the restrictive laws protect professional interests rather than consumers.

The remaining 34 states that restrict APRN's scope of practice will eventually have to come to terms with a growing shortage of physicians and increasing demands to save money and restructure how we receive and pay for health care. The inconsistent, often punitive, and highly politicized regulatory environment surrounding APRNs must recognize the new horizons in medical care in the United States.

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John W. Rowe

John Rowe is a physician and a professor in the department of health policy and management at the Columbia University Mailman School of Public Health. More

From 2000 until his retirement in late 2006, Rowe served as Chairman and CEO of Aetna, Inc., one of the nation's largest health care and related benefits organizations. Before his tenure at Aetna, from 1998 to 2000, Rowe served as president and CEO of Mount Sinai NYU Health, one of the nation’s largest academic health care organizations. From 1988 to 1998, prior to the Mount Sinai-NYU Health merger, Rowe was president of the Mount Sinai Hospital and the Mount Sinai School of Medicine in New York City.

Before joining Mount Sinai, Rowe was a professor of medicine and the founding director of the division on aging at the Harvard Medical School, as well as chief of gerontology at Boston’s Beth Israel Hospital. He was director of the MacArthur Foundation Research Network on Successful Aging and is co-author, with Robert Kahn, Ph.D., of Successful Aging. Currently, Dr. Rowe leads the MacArthur Foundation’s Network on an Aging Society.

Rowe also serves on the board of trustees of the Rockefeller Foundation and is chairman of the board of trustees at the Marine Biological Laboratory in Woods Hole, Massachusetts, and the board of overseers of Columbia University’s Mailman School of Public Health. He is chair of the advisory council of Stanford University’s Center on Longevity, and was a founding commissioner of the Medicare Payment Advisory Commission (Medpac) and chair of the board of trustees of the University of Connecticut.
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