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Keith Barnhill, an advanced registered nurse practitioner who is a certified registered nurse anesthetist, confers with one of his patients at at Grundy County Memorial Hospital in Iowa.
Keith Barnhill, an advanced registered nurse practitioner who is a certified registered nurse anesthetist, confers with one of his patients at at Grundy County Memorial Hospital in Iowa.

Primary dispute

Docs say laws allowing nurses and other practitioners greater leeway endanger patients; advanced practice nurses say they're filling a need that will only grow under reform


By Joe Carlson
Posted: April 5, 2010 - 12:01 am ET
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Though it was dwarfed by the firestorm swirling around national healthcare reform, the long-simmering battle between nurses, doctors and specialty practitioners over who's qualified to do which jobs has reached a new level of rancor and immediacy, those close to the issue say.

Physicians say state and federal lawmakers are increasingly putting patients at risk by allowing lesser-trained nurses, specialists and other “limited licensure” practitioners to encroach into areas of healthcare where they are not qualified to provide patient care. The American Medical Association tracked more than 300 laws in state legislatures last year to expand nurses' powers and is already gearing up for more battles this year.

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Meanwhile, many observers say federal healthcare reform will lead to a spike in interest in scope-of-practice issues nationally, as insurance reforms lead to more access to primary care—which is one of the epicenters in the struggle between advanced practice nurses and doctors over practice rights.

Physicians typically cast the debate in terms of the quality of patient care, but other observers say the argument has deep roots in financial concerns. For example, more insurers than ever are allowing advanced practice nurses, such as nurse practitioners, to bill directly for their services, and some are even paying more than the 85% reimbursement rate that nurses have traditionally received compared with physician compensation for the same services.

“They're really scared that we're going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” says Dee Swanson, president of the American Academy of Nurse Practitioners. “Let's face it: We have a crisis in primary care in this country, and it's an area that physicians have not been interested in, or there wouldn't be a shortage.”

Cecil Wilson, a Florida internist and president-elect of the American Medical Association, says such arguments miss the larger point about patient care, and whether nurses are adding new educational requirements to go along with the additional responsibilities they're seeking.

“We're not talking about protecting what physicians do, this is about protecting patient safety,” Wilson says. “Our concern is that this push for expanded scope of practice is in some ways a way to try to practice medicine without getting an M.D. degree.”

As employers, hospital executives are finding themselves on increasingly unstable middle ground in the scope-of-practice struggle, as they try to balance cost on one hand and quality on the other.

Physicians stridently warn that the quality of patient care will suffer if nurses are allowed to perform tasks for which they are not prepared, which could hurt hospitals' patient-satisfaction ratings and increase liability exposure.

However, hospitals are under intense pressure to lower costs while increasing their patient volume, a challenge that makes advanced practice nurses an appealing alternative, especially when so many of them want to provide services in one area certain to see future growth—primary care.

“When you talk about healthcare reform and what is expected to happen as far as people having more coverage, there is going to be more people needing care. And it becomes a rather crucial question: Who is going to provide the primary care?” says Rebecca Patton, a registered nurse and president of the American Nurses Association.

The AMA takes a stand

Struggles over scope of practice are, of course, nothing new. But the AMA last year ratcheted up the tenor of the debate with the release of a group of reports on 10 limited licensure healthcare provider groups, known collectively as the AMA Scope of Practice Data Series.

The data series was intended to give ammunition to opponents of expanding scopes of practice, including state-level medical societies and medical boards, and included reports on two of the four commonly recognized types of advanced practice RNs: certified nurse practitioners and certified RN anesthetists. The report was silent on certified nurse midwives and clinical nurse specialists, the other two advanced practice RN categories, as well as other “physician extenders” growing in popularity, such as physician assistants. Other areas the data series targeted include dentists, optometrists, pharmacists and psychologists.

The report on nurse practitioners condemns the scope-expansion efforts and explicitly accuses some nurses of trying to prevent patients from seeing their better-qualified doctors, even though some nurses confess to being uncomfortable taking on the additional duties that their special-interest lobbies were handing them. Yet because of encouragement by Medicare billing practices, the number of nurse practitioners has leapt from 250 in 1970 to 139,000 today, the data series says.

The report also challenges nurses' commonly stated notion that nurse practitioners are primarily interested in primary care, when in fact they can be found in all manner of specialties, including oncology.

“There is some irony to the notion that a healthcare professional would discourage cancer patients … from meeting with their oncologist,” the report states. “After all, it is the oncologist ... who has the medical expertise cancer patients expect.”

The nurses' reaction swiftly followed.

“My personal reaction was to scratch my head and say, ‘Gee, that's weird. Why would another profession presume to regulate someone other than themselves?' ” Swanson says. “That's like engineers deciding that they're going to regulate architects. There is overlap in what they do in some cases, but it was very interesting to me that they felt they could weigh in on other sovereign professions.”

That was not how the physicians saw it. The data series was developed as a way to help defend the medical profession from unwarranted encroachment by nurses in states across the country. It was intended as a legislative tool that the AMA's policy advisers can rely on as a counterargument when nurses make the argument to often-uninformed lawmakers about which professions ought to have the powers to do which tasks.

Physicians emphasize the differences in educational levels. While primary-care physicians need a full medical-school education, including residency, the AMA data series says nurse practitioners have varying levels of education and state certification requirements. Not all of them have a master's degree, the report found.

To hear the nurses and their advocates tell it, the evolution toward a system in which highly trained nurses provide more primary care is rapidly becoming inevitable, and the physicians would be better off spending their energy in other ways than protesting something they can't stop.

“Hospitals employ nurse practitioners all the time. … It's a paradigm that is changing, and people are just not accustomed to change,” the ANA's Patton says. “The big driver that people don't like to acknowledge is, it all comes down to the money. Nurse practitioners are seeking to have reimbursement for their services, and some, but not all, physicians see that as an erosion of their earning potential.”

Swanson says many third-party commercial payers refuse to give permission for some advanced practice nurses to receive payment for their services, and those that do often pay at a lower rate than what doctors receive for the same service. Although that inequity in reimbursement rankles many in the nursing world, Swanson offers the kind of solution sure to make physicians' skin crawl: “Our position is, you're not paying us less, you're paying them more for the same thing.”

Doug Swill, a lawyer and vice chairman of the healthcare group at the law firm Drinker Biddle & Reath, says observers should not assume that the AMA was speaking for all physicians in its iron opposition to scope-of-practice laws seeking to give nonphysicians more latitude to practice. “I'm not sure the AMA is really addressing their full constituency,” he says. “But what we're seeing in the physician practices … is an increased use of physician extenders because it's a means of reducing the expense and having more patients seen.”

The Josiah Macy Jr. Foundation, which funds programs designed to improve the education of healthcare professionals, released a report March 4, in consultation with numerous physician leaders, titled Who Will Provide Primary Care and How Will They Be Trained? It recommends that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to provide the care and to lead multidisciplinary teams of primary-care providers.

The AMA was not represented among the dozens of healthcare organizations that signed the Macy Foundation report. The American College of Physicians, whose vice president of practice advocacy and improvement, Michael Barr, was a signatory, immediately issued a two-page statement after the report was released distancing itself from the Macy Foundation's recommendation on removing barriers to having nurse practitioners deliver primary care.

The issue is particularly acute at rural facilities, where recruiting primary-care physicians has been especially difficult over the years because of reimbursement issues and doctors' lifestyle preferences, not to mention the work hours, which tend to be longer and tend not to have as many other options for 24-hour on-call services.

In many sparsely populated areas, the question becomes whether patients are at a greater risk by seeing a provider who hasn't attended medical school, or from not seeing anyone at all.

“Health professionals who are not adequately trained can harm patients. I would not say that having something is better than nothing,” Wilson says.

Making it work in Grundy Center

To which Pam Delagardelle has one response: “I would invite him to come out and spend a week in Grundy Center, Iowa.”

Delagardelle is CEO of Grundy County Memorial Hospital, a critical-access hospital with 25 acute-care beds and another 55 for long-term care in the town of about 2,600 in central Iowa. She says the hospital routinely and happily relies on its crew of nurse practitioners and physician assistants to fill in the gaps when doctors are not available for on-call duties, or during the periods of 18 months or longer that it can take to recruit a new doctor to small-town Iowa.

Although she's an unabashed supporter of using these physician extenders when physicians aren't available, including nurse anesthetists, she also cautions that it takes a nurse with the right kind of background.

Chiefly, the nurses need experience. She likes to see a nurse with several years' experience working in large metropolitan hospitals alongside physicians before giving them more autonomy in rural Iowa.

Texas physician Gary Floyd says that even with that kind of training, he has doubts about midlevel practitioners trying to expand their scope to gain autonomy.

Floyd—executive vice president of medical affairs for the 525-bed JPS Health Network, Fort Worth, and serves on the Texas Medical Association's Council on Legislation—says the nature of nursing education itself augurs against giving many nurses the level of autonomy they're seeking. Nursing schools push a “care and comfort” approach to giving care, as opposed to the scientific perspective of medical schools that teach about disease processes and bodily interactions.

Floyd says he fears that nurse practitioners without adequate physician supervision could get in over their heads with complex patients. “I'm not worried about them taking food out of my mouth. I am much more concerned about quality of care provided to the patient,” Floyd says, and nurse “practitioners being stuck out on a limb somewhere.”


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