Roland Goertz: Thank you, Joe. If I could have the first slide. I have 10 quick slides that I'll review very quickly just to set the stage. The first slide goes through some estimate of shortage in primary care and also in nursing projected by 2020 by the AAFP itself for family-physician shortages and the AAMC for primary-care physician shortages and then the American Academy of Nursing projection of nursing shortages. You see these numbers are fairly daunting—39,000 family physicians, 45,000 overall primary-care physicians and somewhere between a half million and 800,000 nursing shortage positions. And there's some information, and if, indeed, our system moves toward a much more efficient model that's coordinated that these numbers may be ameliorated, but, regardless, primary care and all aspects of it and all the pieces of the team that are needed to present that are in short supply. One of the questions asked today is whether or not the system could address this. And we have seen the system move toward addressing it with the education model and [unclear: 3:40] have high hopes that that is true. Next slide.
The IOM's Future of Nursing report, and Penny and I were both meeting yesterday—I think Penny is still there; I had to return—lists several recommendations, and they are listed on this slide. Not all of them. There are eight formal recommendations, and these summarize some of them. Remove scope of practice barriers, nurses should practice to the full extent of their education, nurses should achieve higher education levels and more standardized education levels. And nurses should be full partners with physicians and other professionals in redesigning healthcare, and effective workforce planning is needed. Next slide.
The factors that are affecting primary-care workforce also are in many ways also impacting nursing shortages. In primary care, there's a cap on residency training physicians. There's a lack of education dollars to support expanding those. The dynamics within hospitals, particularly teaching hospitals, are much more favorable to subspecialities, and there's inadequate support for graduate medical education. [4:55 ?I think if you're Title VII dollars.] Under the nursing arena, from our perspective, there's also an inadequate support for nursing education programs with a particularly significant shortage in nursing faculty and shortage of doctoral-trained nursing faculty to teach [unclear: 5:05] Next slide.
The academy in the early 2000s developed, resurrected and re-energized a model of care—called the patient-centered medical home. This model has gained significant policy traction, and it is about team-based care using the expertise of physicians, nurse practitioners, physician's assistants and other significantly important parts to primary-care delivery team. And in that model, nurses can play a pivotal role in the patient-centered medical home. And I want to correct something here about the patient-centered medical home that I've been asked to address many times. The patient-centered medical home was created by primary-care physicians groups, particularly the American Academy of Family Physicians invested a significant amount of its own resources and members' resources to look at what's family medicine and what primary-care physician practices needed to be in the future. I often get asked why it doesn't include others. Well, it was designed specifically to address family physician and other primary-care physician practices, and that's why. It wasn't designed to redesign nursing as the IOM (Institute of Medicine) report is, and certainly I wouldn't expect the IOM report to have significant elements of family physicians embedded in it, which it does not. Next slide.
There is significant differences in educational tracks. One of the things that's embedded in the IOM report is an urging to the nursing educators to put in more standardized and seamless acceleration of teaching and learning in place for nurses across the board. Regardless, the models are significantly different. This slide depicts the difference in clinical exposure, particularly for family physicians that end up with 15,000 to 16,000 clinical hours. Nurse practitioners are at 500 to 1,500 clinical hours, so there's really not an issue. Equivalency is an issue about what should be the standard in training. Next slide.
Continuing education and recertification are very important. One of the IOM's report is to have nurses become ever-learning. Family physicians recertify every seven to 10 years with a minimum score of 80% on all of the tests and competency areas and then moving to a very significant change in how competency is assessed. There's 300 hours of continuing medical education that's required, giving 50 hours a year to maintain state licensing in most cases. Nurse practitioners have not addresses that yet. They waive recertification with 1,000 hours of professional practice over five years of the certificate period. Next slide.
So, in summary, the primary-care community, and particularly family physicians, strongly support the collaborative practice and the team approach to primary care that's embodied in the patient-centered medical home. And nurses play a very important role in all of that activity in a teamwork model. We also support enhancements with the standards of nursing education and the national efforts to generate more nursing faculty resources. We believe that there should be more resources applied to all of primary-care elements and certainly reinvigorating all of the pieces that would deliver that patient-centered medical home and patient-centric home are needed in the future. In these types of addressing the standards of education, should be proposed before significant changes of scope are discussed. And with that, that's the end of my slides. Thank you.
Joe Carlson: Great and, you know, Dr. Goertz, if I could ask a follow-up question: You mentioned patient-centered medical homes, and this is obviously a subject that's been talked about quite a bit. How do you define exactly what that is? What's your understanding of the definition of patient-centered medical home?
Roland Goertz: Well, the American Academy of Family Physicians did a future of family medicine project in the early 2000s, and it found out a lot of information about what we were and were not doing well within our primary-care practices, particularly family medicine practices, and the patient-centered medical home and the medical-home concept was originated by pediatricians in the '60s was resurrected by that report in redesign that included a lot more patient-centered activities such as open-access scheduling, use of modern electronic tools, teamwork concept of care instead of it being focused only on the individual physician so to speak, using the team and all of its attributes moving forward. And the four large primary-care physician groups defined a set of unified attributes to in February of 2007. Now, unfortunately, a lot of people don't understand that definition or where it came from and have jumped on the bandwagon in wanting to be part of it. But the origins of that are based in redesigning physician practices in primary care, and our organizations don't have any problems with including others in the neighborhood around that, but the focus was on redesigning primary-care physician practices—not the whole system because we had enough to do with looking at what we needed in the future.
Joe Carlson: OK, great. Next we will hear from Penny Kaye Jensen, president of the American Academy of Nurse Practitioners. Penny.
Penny Kaye Jensen: Good morning. I would just like to start with talking a little bit about—if I could have my first slide, please—the Institute of Medicine and the Robert Wood Johnson Foundation report that was released in early October. And the report assesses and offers recommendations for the future of the nursing profession in the United States. Nurses should practice to the full extent of their education and training. This was one of the recommendations that was released in October. Nurses should achieve higher levels of education and training through an improved education system that promotes a seamless academic progression. And nurses should be full partners, with physicians and other healthcare professionals, in redesigning the healthcare in the United States. We should have an effective workforce planning and policy to require better data collection and improved information infrastructure. The report also forecasted, as Dr. Goertz spoke about, the major physician shortage that will be exacerbated by the expansion of coverage under the new healthcare reform law. Thirty-two million Americans will now be eligible for health benefits and insurance, and we already know there are not enough primary-care physicians or primary-care providers in the United States to meet the demand. Next slide, please.
For nearly half a century, NPs have provided high-quality, cost-effective, comprehensive and personalized healthcare to patients. We are highly skilled clinicians who diagnose, treat and manage chronic illness very well. NPs prescribe medications and provide treatments such as ordering and performing, interpreting diagnostic tests, lab work and X-rays as well. We really focus on health promotion and disease prevention, and including education and counseling with our patients. And that's an integral part of the care provided by nurse practitioners. And that is really something that we do well. Our patients are very satisfied in the satisfaction surveys that have come in time and time again with the time that we spent with them and the time we spent counseling them. NPs have really differentiated themselves from other healthcare providers by focusing on the whole person when treating specific health problems, as well as educating our patients and their families and also working with the communities in which the patients we serve live in. The hallmark of NP care is really to partner with our patients and to find care solutions that will work best for their needs in their lives. And I really think that's where nurse practitioners fit in very well with the medical home model. Next slide, please.
The high level of patient satisfaction with the care provided by NPs is demonstrated by how many patients see us each year. This is documented at 750 million visits. Multiple studies have consistently demonstrated that our patients' outcomes are equal to that of a physician. And yesterday during the meeting, the IOM report—they focused on just what a robust review process has to happen before they will accept recommendations and make recommendations, and they have a strong reputation of very much looking at the evidence before they ever release a recommendation. And it was said yesterday in the morning session that core primary-care activities with NPs are the same quality and the same safety as that of a physician. And in some cases, NPs actually have better outcomes. And NPs may be trained for a longer period of time, but when you look at the evidence, our outcomes are better or equal to theirs. I believe strongly that it's just a different framework. They have a medical framework. We practice with the nursing conceptual framework. NPs practice in many different places—rural areas, urban areas and suburban communities. I live in Utah and I'm very familiar with the West. Twenty percent of our population actually resides in these rural areas. Eighteen percent of NPs practice in rural areas, while only 9% of our physician colleagues practice in these areas. Nurse practitioners are more likely to stay and practice in rural areas than our physician colleagues. And, again, as that is an issue of access to care, our patients—especially with the grain of America—are older patients that live in these areas need to be able to have healthcare services. Malpractice rates remain low with nurse practitioners; less than 2% of NPs have ever been named as primary defendants in malpractice cases. Next slide, please.
I want to talk for a moment about the role of regulators in promoting the expansion of nurse powers and duties, and it really—the federal regulators really have the responsibility to promote access to quality care and to remove federal barriers to this access. The IOM fully supports the full utilization of NPs in their roles, and they have already equipped to provide the role that they are already filling in 14 states and the District of Columbia where nurse practitioners have plenary authority and are able to work to the full scope of their license. The utilization of NPs provides an opportunity to ensure that the healthcare workforce is being implemented to its full capacity and that all patients in all states, as I said, will be able to have access to care. The IOM report supports extended utilization of NPs, as we pointed out, and many legislative problems exist with that. Some legislative issues that are a problem are the patchwork of states when the scope of practice issues that we do encounter. So, for example, I'll touch on a federal issue. The Medicare provision from 1965 requires that physicians order home health for Medicare patients, and today nurse practitioners all over the country order home health for patients with commercial insurance. But with Medicare patients, they must wait for an added physician's signature to seek an additional appointment with a physician to require these services. There's a 50-year-old requirement in delaying care and driving up costs that hinder the effective use of the full healthcare workforce. We have similar examples of outdated policy in both the state and federal that are interfering with care and the role of the federal regulators, like I said, is really to update these policies to reflect the education and the skill set of providers to meet the 21st-century care that we cannot underestimate. There are more than 140,000 educated, skilled and willing nurse practitioners in the United States to meet the care needs, and, as I mentioned, but outdated legislation prohibits us from working to our full scope in many of our states. NPs are underutilized, again, because of obsolete policies.
The capacity of educational systems from nurses and doctors to produce enough providers to meet our future demands. The volume of providers alone is not going to address the needs for the future. We know that, as I have mentioned and Dr. Goertz has mentioned, there is already a severe shortage of primary-care providers. We do have 9,000 NPs that are prepared each year in our 325 colleges and universities. And we need to maximize the full scope of education and skills that each discipline of the provider brings to the workforce and ultimately meets the healthcare needs. Solving the crisis of our healthcare dilemma. Next slide, please.
The role of the nurse practitioners in team-based medicine, particularly the medical home. Producing a healthcare system that delivers the right care, quality care, that is patient-centered, accessible and that stays sustainable at the right time will really require transforming the work environment, scope of practice and education in numbers of America's nurses. And team-based medical care team members must be skilled in communication and coordination. We must be able to function to our full capacity. Again, the IOM has addressed that with wanting advanced-practice nurses to practice to their full scope. NPs embrace and support well-coordinated and integrated care and are well-prepared to lead and participate in team models of care. I have been in the VA system for 17 years. The VA has utilized nurse practitioners for a very long time in various settings: primary care and also in all of our inpatient settings. In addition to our role as primary-care providers within the VA system, NPs serve as healthcare researchers, and we apply our findings over a variety of settings we practice. The results of the VA initiatives using both front-line RNs and also APRNs are extremely impressive. Quality and outcome status consistently demonstrates the pure results for the VA's approach. Once they found that VA patients actually received significantly better healthcare based on various quality-of-care indicators that patients who were enrolled in Medicare fee-for-service program. The medical home model actually mirrors the NP model of care: personal provider who focuses on the whole patient, provides coordinated and integrated care that is high quality and safe and that enhances access. NPs are highly skilled and qualified as primary-care providers and serve as leaders in these models. NP-led clinics should be the medical home model. And I am a strong believer in parity. I believe that we should work together. I believe that the medical home is about the patient, and I believe that nurse practitioners practice healthcare. We want to take care of our patients, and therefore I feel very strongly we should be included in the medical home model and be leaders in the medical home. And again, I'll just say that the Affordable Care Act of 2010 will place demands on the healthcare profession, but it will also offer many opportunities to create a system that is more patient-centered. And I truly believe we can work very well with our physician colleagues. We can be a part of the team. We can lead teams. And we can transform healthcare in America. Next slide, please.
NPs have a unique opportunity to transform America's healthcare system. And, again, as I mentioned, to transform healthcare, NPs are the healthcare providers of choice for millions of Americans already of all ages, all walks of life and in all communities. NPs are performing many of the same functions as he physicians including prescribing medication and performing physical exams for nearly half a century. It is important to embrace the full education and skills of nurse practitioners and refine outdated policies and regulations that prevent us from working to our full capacity and therefore interfere with patient care and access. Thank you.
Joe Carlson: Great. Thanks, Penny. And I'd like to ask a follow-up question, but before I do, I'd like to say that we have a pretty good group here on the line today and if listeners want to continue to submit questions, that'd be great. Penny, I'd like to ask: You mentioned the differences between the medical and the nursing conceptual framework for care. Is there any—I know it's a complex question—any way to quickly summarize what you mean by that—the medical vs. nursing conceptual framework? OK, great, well, I think that …
Penny Kaye Jensen: I'm here. I just got knocked off the cast.
Joe Carlson: OK.
Penny Kaye Jensen: Sorry about that. Could you just ask the question again, please?
Joe Carlson: Yeah, absolutely. You mentioned your feelings about the medical vs. the nursing conceptual framework for care. I just wondered if you could explain that—what that is exactly?
Penny Kaye Jensen: Yeah, before a nurse practitioners enter nurse practitioner school, they must have a bachelor's degree. And so every nurse that enters the NP program has already attended a four-year BSN program. The average amount of time that those of us have practiced prior to entering the NP program is 10 years. I will speak for myself. I was an intensive-care nurse for 10 years before I ever entered an NP program. So I think the majority of our experience in education is on the front end where I see the physician model is medical school and then a residency, and they get their clinical hours on the backend. And I truly feel that our hours that we should spend as registered nurses working at the bedside, working with our patients, should really count toward our hours—our clinical hours—and I feel our education is a different model, but I do not feel it is any less than that of a physician.
Joe Carlson: Ok, well great. So the first question we're going to go to—I'm going to ask Roland Goertz to address it first. You know a lot has been said in the debates about this topic recently and over the years. And I wondered: What do you think is the main point that is sort of lost in all of the discussion? What's the point that maybe doesn't get enough attention that you think should be made?
Roland Goertz: Well, I think the debate always sort of comes back to this issue of independent practice for nurse practitioners and how that is framed and based on what? The Institute of Medicine report goes through very lengthy explanations of the problems within the educational system of nursing at all levels. The statement yesterday at the meeting was essentially that with available evidence, there is equal or similar outcomes for primary-practice services between nurse practitioners and some physicians. The problem is: What's that definition? If you take away all certification barriers and don't define what those core primary-care services are, I don't know how you protect the safety of the public without any type of certification process and placement when you don't know what the standard of training is that results in what level of core primary-care services can be provided. The American Academy has always said that there are many individuals that can provide primary-care services, but primary-care services cannot equal what a family physician can provide to the patients and patient care in an ongoing way. So, it's imperative, I think, for the nursing profession in the IOM report and the RWJ as they roll this out to put much clearer definitions about what it is they're asking should be removed, and, then, when it's removed, what is certification and safety for patients going forward going to be based on because that's lacking?
Joe Carlson: And, Penny Kaye Jensen, I would ask you the same question: What do you think is the main point that has been sort of lost or not mentioned enough in all of the debates on this topic?
Penny Kaye Jensen: Patient-centeredness. I think that in all of this debate, we are forgetting the patient. And that is very unfortunate because the medical home model, again, as I spoke about, really focuses on the patient. And really the patient is the point of the healthcare system, and that's who we all should be focusing on as a team—physicians, all the allied healthcare professionals and nurse practitioners. Though I strongly believe it's patient-centeredness.
Joe Carlson: OK, and we have another question here, and I think we should start with, again, Roland Goertz for this one. Given the history and opposing interests of physicians and advanced-practice nurses, do you think there's an expanded role for APRNs that physicians could ever accept?
Roland Goertz: Well, I definitely think so. I mean I'm living proof of it. I'm the CEO of a federally qualified health center that has teamwork that has been in place for 14 years, well, actually over 14 years. We have family physicians and nurse practitioners paired together, working seamlessly to deliver care to a population of patients that need more than just those two can provide. And then we have support services that include nutrition counseling availability, other case-management capabilities and a true teamwork. So I think that there's a lot of common ground. I mean, Penny's organization represents about 21% of all nurse practitioners, according to at least the data that I have. And the data yesterday that the IOM says that about 10% of nurse practitioners, maybe 16%, do want independent practice, and I, honestly, as long as we get the definitions of what that means and what that composes, what those core primary-care services are encompassed by that, I think we can have a lot more common ground. But there's a lot of—in fact, when I go to meetings, the majority of family physicians, particularly if it's a family medicine meeting, are already working with nurse practitioners in very creative ways to help address patient care.
Joe Carlson: Do you think there's a leadership—an expanded leadership role—for advanced-practice registered nurses that physicians could accept?
Roland Goertz: I see nurse practitioners and other nurses in leadership roles in hospitals and health plans all over the place, as many, actually, in those roles as I do see physicians these days.
Joe Carlson: OK, Penny Kaye Jensen, a question for you. Is it the goal of the AANP to substitute for or replace primary-care physicians?
Penny Kaye Jensen: Absolutely not. We just would like to be able to take care of our patients and work to the full scope of our licensure. I work—I think all of us I can speak—many of us have worked for years with physicians, and the majority of nurse practitioners within our organization work in private practices with physicians. I have worked hand in hand with physicians through the VA system, and our organization is not saying that we want to replace the family physicians, but we want to meet the healthcare demands of the nation. And, again, with the 32 million individuals that will qualify for healthcare benefits with the healthcare reform act, I think that nurse practitioners are an excellent solution to complement and work in the primary-care setting.
Joe Carlson: And in terms of the leadership aspect, do you think—where do the advanced-practice nurses fit into leadership?
Penny Kaye Jensen: They can lead practices. Many nurse practitioners work in nurse-owned practices, and we, again, within the VA system, I will relate to that, we have led patient panels for many years alongside of our physician colleagues. So I believe that nurses can be leaders in the medical home and I think that we will continue to provide excellent care to our patients and alongside of our physician colleagues.
Joe Carlson: Penny Kaye Jensen, this is another question for you: There was reference to studies on comparing nurse and doctor quality—isn't it hard to believe that nurses make no more mistakes than doctors given the differences in training?
Penny Kaye Jensen: Well, I think that we have studies, and the studies are posted on our website, but when we review the studies, there is not one study that shows that nurse practitioners' outcomes are not safe or are poor. And I'm going to say maybe it's time that we look at our educational models. Maybe the traditional medical model is no longer working. We seem to have the same outcomes as our physician colleagues, and our model is different. And, again, I'm not comparing the two models. One is nursing, one is medicine, but our outcomes are equivalent to them.
Joe Carlson: Roland Goertz, any thoughts on that point?
Roland Goertz: Well, you know, the studies that are out there are based on what I call ‘point-care analyses.' In other words, if a set of nurse practitioners are taking care of hypertension or other illnesses, is the set of outcomes that are analyzed in that data equal to or better or worse than another physician caring for them? And I anticipate—and I haven't read word to word, I mean, the first to last page all of the studies cited in the IOM report—I trust that the Academy of Sciences did their due diligence with that. But when you look at point-care to point-care issues, it's easy to see how a care level could be equal when you're dealing with a set of specific care outcomes. Also, they're relying an awful lot on satisfaction studies, which are incredibly important. That's the patient-centeredness that we're urging all primary-care physicians to address in a large way within this redesign of the patient-centered medical home for primary-care physician practices. The real issue is that studies have not been done, and maybe they would be very difficult to do if you did an all-comers analysis. In other words, if a nurse practitioner clinic had no barriers to what those core-services definitions are, and they see an undifferentiated patient come in or a very complex patient come in, how would the outcomes be from what their analysis would be of that patient vs. the physician analysis? Those studies are wanting and are not out there. I'm more than willing to accept that point-care studies might be equal, and are equal based on the information the IOM has produced, but I'm also clearly aware of point-care studies that show that, you know, cardiologists may not do as well as primary-care physicians in some issues. But we don't—you know, point-care studies are difficult to analyze, but there's more than enough that show that nurse practitioners have adequate outcomes on those point-study outcomes.
Joe Carlson: Any response to that, Penny Kaye Jensen?
Penny Kaye Jensen: Well, I would just say that we do manage complex medical illnesses, and, again, working in the VA, there's some of the most chronic, comorbid conditions that patients can have, and our outcomes are very good. And I would say, if I were to look at the data and look at the studies, and as I read through some of the studies that came from the IOM report, there's a meta analysis that includes 25 articles relating to studies comparing the outcomes of primary-care nurses and physicians, and so there are many studies that are documented, and I will just refer you to the Web—our website—to look at those.
Joe Carlson: Roland Goertz, I wonder if you have any thoughts on who would be the entity that would conduct such a study? It seems like each side has their own set of studies at least on other issues that I've looked at. I mean, who might be an impartial enough group to be able to do a study that would look at, as you say, point of care?
Roland Goertz: Well, there are a number of potential entities to do so. Our own congress of delegates this past annual meeting that we had in September, has reached the level of sort of frustration to the sense that, ‘Well, let's just do these studies. Let's do the significant, large-scale studies.' We've actually asked a research arm how possible that could be. There are some RIB issues that you'd have to address to try to understand how to set such a true analysis or comparison of, and I'm not sure exactly how you could do that. And obvious entity could have been the IOM, but the IOM, you know, now had positioned itself in a certain way that a lot of members would not—I'll just honestly say—trust the outcomes of it because they've taken already a position that's one way. I would hope that regulators and maybe comparative effectiveness research studies might be able to embrace this or the Medicare Innovation Center might be able to look at different models of care. But honestly, Joe, one of the things that we're moving toward is not independent practice anyway; it's team-based practice where none of us are independent in how we care for patient care. It's way too complicated these days to adequate care for patients in this very complex medical world. And we need every part of the system working together as teams, not fighting each other over these issues.
Joe Carlson: Next question is for Penny Kaye Jensen.
Penny Kaye Jensen: I just want to say I very much agree with Roland on that, and we welcome any studies that they would like to do. I think it's important to look at these things, and we are in total agreement that it is a team-based world now.
Joe Carlson: And, Penny Kaye Jensen, new question: Nurses can become NPs through online universities as well as obtaining a DNP, a doctorate of nursing practice. How do these programs compare to medical school and residency? And, if I could add to that as well, the IOM report has some recommendations on standardization of education for nurses. And I wonder how you feel about what they recommended in that report? I guess that's two questions.
Penny Kaye Jensen: Well, I'll talk about the report for a moment because they want to increase the number of bachelor's-prepared nurses by 80%. They want to not phase out the associate-degree programs, but use that as a way to encourage individuals to become nurses, and that will also help a diverse group into the nursing field. But then they really want to encourage the nurses who achieved the associate degree to further their education and become bachelor's prepared. And that was one part of the report. We want to have more nurses who are leaders, and in order to do that, we want to increase the amount of nurses that do hold a doctoral degree, and so that was part of the report.
As far as the online programs, programs that I am familiar with do offer some online classes. Online does not substitute for clinical portion of our training. So programs are standardized, and they have to be accredited.
Joe Carlson: And didn't the IOM report have a recommendation—am I recalling this right—three-quarters of registered nurses ought to have four-year degrees within a certain number of years?
Penny Kaye Jensen: Yeah, I believe it said 80%.
Joe Carlson: Do you agree with that? Is that realistic and doable?
Penny Kaye Jensen: I very much agree with it. And I do. I'm hopeful. I do think that it would be something that would help our profession is to increase the education—absolutely at that entry level.
Joe Carlson: Roland Goertz, you mentioned—you touched on the subject in your intro, and I wonder if you might like to expand a little bit: How do the education system for nurses—all the way from online RN degrees all the way to doctorate nursing practice—how does that compare to medical school and residency training?
Roland Goertz: Medical school issues, similar to this, were dealt with back in 1910 with the Flexner Report. There was significant identification of nonstandardized education. A lot of the IOM report on nursing education indicates that there is not uniform standards applied to the various levels of education for various levels of nursing certification. The way the medical world dealt with that is they created a national entity that oversees and accredits medical schools both osteopathic and [unclear: 40:15 ??homeopathic??] schools from a curricula viewpoint and separated the curricula education fees from the certification fees. Certification fees is still left in the states, so one of the things I think the IOM report could have done and does in a way recommended is that there be national standards for education that could be applied, because the states-rights issues for licensing and certification, I don't think the constitutions allow for that to occur. But instead allowing it to reside in the states, where a lot of variability on education can still exist, is not going to solve this issue of what is the standard of education competency required in the kind of curriculums that are needed.
Joe Carlson: Roland Goertz, I've got another question for you: To start out, nurses often argue that they provide primary-care services in places that doctors don't practice. Do you think patients are more at risk not receiving care or receiving care from a clinician with less training? I'm guessing that's a reference to [unclear: 41:10].
Roland Goertz: Yeah, and it's also a reference to what I hear when I talk to policy people and sometimes legislators. There is a significant thought and opinion that some care is better than no care. And I will agree that some care is better than no care when that some care is appropriately certified, appropriately competent and appropriately licensed to be provided. And that's really the core of this discussion: Is how do you get the nursing education model to that level of understanding? When we have an opening for a nurse practitioner in our clinic system, or a physician for that matter, but physicians the standardization is much more understood. For nursing, the standardization is not as well understood. Now I agree with Penny 100%: If we hire the right person to be parts of those teams and over time we understand how that team of the doctor and the nurse can work very well together, but the very ability with who we bring into those positions some not with the 20 years of ICU experience that Penny had but right out of nurse practitioner school, is immensely variable and takes time to understand what that is. So the nursing profession would help itself significantly if there was better standardization of what the product and competency is coming to the system to be part of the teams.
Joe Carlson: Penny Kaye Jensen, any thoughts on patients receiving care from nurses in [unclear medicallu?] underserved area?
Penny Kaye Jensen: Well, the one thing I just want to point out is we do have national standards of education and that's with national accreditation of programs. I think we just need to do a better job in communicating that. And, for your question on underserved populations, as I said, many nurse practitioners work in the rural areas. Many folks who live in rural areas tend to be underserved, and I think we very much meet a need in those areas. The other thing I wanted to talk about was Medicare, and 81.3% of NPs accept Medicare patients, and we also—83.5% of NPs—accept Medicaid patients, and so we do definitely serve a group of individuals who would otherwise not receive care.
Joe Carlson: OK, great. Penny, I would again start with you with this question and it has to do with the specter of reform that hangs over everything: Are healthcare financing pressures and the stress of reform influencing this debate more than they should be?
Penny Kaye Jensen: I don't think so. I'm not sure I understand what you're asking me.
Joe Carlson: Do you think that—and I'm interpreting here—the pressure of the various requirements and goals in the reform law, are those putting more emphasis in parts of the debate and less on others and sort of distorting the outcome or is the—maybe the pressure is a good thing. Maybe this is what needs to happen now.
Penny Kaye Jensen: No, I think it is a good thing. I think it is what needs to happen. And as obviously as Dr. Goertz said earlier, I mean we've already been suffering a shortage in primary-care area for years before healthcare reform even was talked about, and now I think it's just brought it to a head, and we realize we're already behind the eight ball and now we have more patients that will be entering the system and who are going to take care of them? And here we are. We're ready to do it.
Joe Carlson: Roland Goertz, this is a question we had advertised in the magazine. There was a recommendation in the IOM report about federal regulators having a role in promoting the expansion of nurses—both their powers and their duties—and I wonder what you think about that subject? Do federal regulators have a role to, for example, put pressure on states through funding mechanisms to change their scope of practice laws? Is that type of action appropriate or not?
Roland Goertz: Well, I partially addressed that in one of the previous questions. I think that the ordering of the sequence of things has to be addressed first. I think that you must address the appropriate standard of training so that it's understood what is produced from all the nurse practitioner schools and exactly what competency levels of those primary-care services that are in that evidence say that can be done. Then you create the case that there should be licensing and/or certification based at that level of competency. I don't know where that level of competency is right now. And so I don't know that I should expect the federal regulation to pressure the states when the federal regulator can't say where level of competency is set—at what standard is that? Because if you take away all certification, then, you know, I don't really know what the limiting factors for patient safety would be within that model.
Joe Carlson: Penny Kaye Jensen, any thoughts on regulators' roles in changing the scope of practice or otherwise encouraging acceptance of APRNs in the system?
Penny Kaye Jensen: As I said earlier, our competencies are there. We have to be accredited [unclear: 46:45] do. I just think we're not doing a great job of communicating that.
Joe Carlson: Penny Kaye Jensen, a question here. With more nurse practitioners going into primary care—you know what, I'm sorry, maybe we should pose this question to Roland Goertz first. I'm sorry. Roland Goertz, by more nurse practitioners going into primary care, do you think that further persuades medical students to not go into primary care, and does that further compromise patient safety as less physicians are providing primary care?
Roland Goertz: Well, I think that one of the unfortunate things that's happening is that there's a blurriness of the lines between what is the nursing model that Penny has very well described versus the medical model. And I, myself, unfortunately, have had very good candidates for medical school tell me that others have said, ‘Well, why spend that much time going to medical school; you can do the same thing going to nurse practitioner school.' And I don't think that's good for the model moving forward because we need both primary-care physicians and family physicians that are well-trained, and we need nurse practitioners that are well-trained, and we need PAs that are well-trained, and we need nutritionists that are well-trained, and we need case managers and behavioral counselors and a whole host of others to do this job well with very good communication between the two. So, I think unless you give credence to all of those important elements of the team and in the way that they, themselves, can be the most significant contributor to the team, you have a very significant chance to imbalance the system, which is partially happened already.
Joe Carlson: Penny Kaye Jensen, any thoughts on whether nurses moving into more primary care might discourage even more physicians from also going into primary care?
Penny Kaye Jensen: I disagree wholeheartedly with Dr. Goertz' comments. I see it within the system I work in. You know it's very difficult to keep the residents may come back and work for a couple of years that they tend to go on and work in specialty practices, and I think that's just a decision that they make. And I definitely attribute it to the primary-care shortage. I'm not sure how the physician community can encourage them to stay in primary care. I work with them every day, and many of them just don't like it and they want to do specialty things. But I agree with what he said.
Joe Carlson: Penny Kaye Jensen, I'll start with you for this next question: Can you comment on the healthcare costs associated with malpractice litigation and malpractice insurance for independent nurse practitioners? It would seem that malpractice costs and litigation would rise, and thus far I have not seen this addressed in any comparison of cost of nurse practitioner-provided care. The comment earlier about only 2% of nurse practitioners being sued reflects the physician-led team approach in most of the states.
Penny Kaye Jensen: We have a very good record as I pointed out in my slides. We have a very good record of not having malpractice suits against us. I think between 8(,000) to 10,000 nurse practitioners in the United States own their own practices, but I am not aware of any data that shows that they are sued any more frequently than family-practice physicians or any physicians for that matter.
Joe Carlson: Roland Goertz, any thoughts on healthcare costs involving malpractice for independent nurse practitioner practices?
Roland Goertz: I wouldn't expect—I agree with Penny—I wouldn't expect that there would be any significant change. I think the issues that are more involved with that is looking at an overall system efficiency. How does the incorporation of that type of model into the current system change exactly how the pieces of service that are needing to be much more better coordinated for patient-centered care are going to be impacted by the expansion of one segment of primary-care delivery over another. I don't really anticipate that the medical liability issues would be different as long as you can resolve this issue of what certification of competencies—at what level of those primary-care services are indeed able to be certified.
Joe Carlson: Penny Kaye Jensen, let's start off with you for this next question. Where do nurse-run convenient care and retail clinics fit into the accountable care organization—or, I'm sorry—the ACO or the medical home environment? And are these clinics a threat to the traditional doctor-patient relationship do you think?
Penny Kaye Jensen: Not a threat. I feel that they're actually a good referral source to our physicians and to nurse practitioners. And I would not see a retail clinic being a medical home. They're taking care of acute issues that arise and they are there to meet the need for the parent who may not be able to get their child into a pediatrician or a nurse practitioner, so I feel that they're a very good referral source for all of us.
Joe Carlson: Roland Goertz, any thoughts on nurse-run convenient care and retail clinics in terms of the ACO model or the medical home model?
Roland Goertz: Well, I think without knowing exactly what the rules are going to allow ACO models to be in the future, which are not going to be released until January, it's a little hard to comment. Now, the convenient care clinics are serving obviously a need that the public and patients are finding acceptable in many ways. I firmly believe that patient-centered medical home practice can provide those same services. And that's one of the things that we, as a professional organization, are urging our members and their practices to try and consider doing is: Keep that all in the circle of the whole patient-care model and incorporate those types of methodologies of those quick clinic availability within their own practices.
Joe Carlson: So you wouldn't see the clinics as a threat to this traditional doctor-patient relationship?
Roland Goertz: Well, I think that one of the issues is communication and what's done in those clinics, and that information not getting back to essentially whatever medical home the patient has. If it's left as information out there hanging, it simply furthers the fragmented system and inefficiencies within the system.
Joe Carlson: Penny Kaye Jensen, are there any clinical areas that you think carry a lot of potential growth for the use of APRNs, and which clinical areas might not have as much growth, might carry a low potential for growth?
Penny Kaye Jensen: Well, as we talked about: I think primary care is definitely the place where you'll see the growth of the nurse practitioner profession—obviously because of the need, but another thing that I'd like to bring up is because of where we're trained, nurse practitioners we spend our training in the primary-care setting and so when physicians, and maybe this could explain why their model takes a longer amount of time, they spend time learning how to deliver babies, spend time doing orthopedic rotations and, as far as nurse practitioners, we spend our time in a primary-care setting. And so the majority of us end up going to work in a primary-care setting after we have graduated from our programs. And we tend to stay there.
Joe Carlson: Roland Goertz, any thoughts?
Roland Goertz: I believe that there will be more than enough needs of patients that are newly covered in the redesign of our healthcare system, for all of us to do a much better job at providing primary-care services for patients. I think that nurse practitioners working together with family physicians and other primary-care physicians in a teamwork concept we prefer and promote the patient-centered medical home model can incorporate innovative and creative ways of doing care that are more efficient than we ever envisioned. And I would suggest that working together in resolving some of these issues and understanding each of our strengths is really going to be the answer moving forward and not dwelling on the differences of opinion
Joe Carlson: And I think we have time for just one more question here, and it goes back to where we started, and I think I'll start with Roland Goertz here: What do you think should be the role of the nurse in the team-based approach to medicine, including medical home? What specifically should be that role do you believe?
Roland Goertz: Well, I can explain it to you from our own experience here. When we create the partnership between the nurse practitioner and the family physician here, and they vary a little bit because we operate some school-based clinics where the nurses do run that clinic in connection with their partner physician and vice versa, but not with the physician there all the time. And, as you learn your patient population, there are sets of patients that are very congruent with those evidence-based, primary-care services that can be provided by nurse practitioners extremely well, and then in case a patient has an issue of complexity that is not within that realm, then there can be a seamless set of communication with the family physician about what the needs of that patient are and how they can be served. And that's how it works in our model, and it works extremely well.
Joe Carlson: Penny Kaye Jensen, any thoughts on what specifically should be the nurses' role in this model?
Penny Kaye Jensen: Could you clarify? Do you mean the nurse practitioner or the RN?
Joe Carlson: I'm sorry, the APRN is what we've been discussing.
Penny Kaye Jensen: OK, I can speak from working within the VA system where I manage my panel of patients and have done so independently since 1997. And we are now incorporating the medical home into our setting where, really, the RN will be the care coordinator, who will be the center of the wheel so to speak, and the physician, nurse practitioner and all of the other groups that are included in the medical home will be taking care of the patient. And, again, it will be very patient-centered and we will work together. A unique and innovative thing that the VA is doing and they put out a call for proposals, and I am very happy that this has happened—that they want to get the residents and the nurse practitioner students to work together in a medical home and co-manage a team so that we can work together on increasing our communication, work as a coordinated team and we will share the accountability for one patient team. And I think if that happens early on in education for both of us, I think that we will work much better together when we get out of our respective programs and go into practice.
Joe Carlson: Great, well thanks everyone. That is all the time that we have today. I'd like to thank our panelists for their time. We heard from Dr. Roland Goertz, president of the American Academy of Family Physicians, and Penny Kaye Jensen, president of the American Academy of Nurse Practitioners. In summary, the role of the APRN is gaining momentum in the primary-care healthcare workforce, however, that is also raising serious questions about the exact boundaries of APRN care and what training ought to be used to support it. As nurse and physician groups continue to press the issue in the public, one thing that seems sure is that the debate isn't ending anytime soon, particularly with all the focus on the medical home model of care. Thanks everyone. This is Joe Carlson from Modern Healthcare.
David May: Thank you, Joe. This concludes today's discussion of the new roles and responsibilities that have been proposed for nurse practitioners. We thank our panelists for participating and thanks to all for joining us today. For those who want to listen to this webcast again, all attendees will receive a follow-up e-mail with a link to the recording of this event available on ModernHealthcare.com/webinars. Thank you.