But regulations in many states do not allow nurses to carry out those duties, in part because organized medicine—physician associations—have opposed efforts by nursing groups to expand their authority.
The AANP has targeted 34 states with restrictive regulation of nurse practitioners, sometimes known as scope-of-practice laws. All require physician oversight for nurse practitioners to prescribe medications and a dozen require physician oversight if they diagnose and treat patients.
Modern Healthcare's 11th annual workforce report focuses on the issues facing nurse practitioners and physician assistants as their roles continue to evolve.
Nurse practitioners already routinely evaluate patients and manage episodes of care. That will only grow with the Affordable Care Act's focus on the coordination of care and population health.
But midlevel providers aren't the only ones who might benefit from less-restrictive scope -of-practice laws.
Ann Davis, senior director of state advocacy and outreach for the American Academy of Physician Assistants, tells the story of a family physician practicing in North Dakota. While that state allows nurse practitioners to work with minimal physician supervision, it's more restrictive with physician assistants, requiring on-site physician supervision. The state does not take advantage of Internet video conferencing or other technological advances in allowing remote PA supervision.
As a result, Davis says, the physician had to spend a large part of the day in her car driving from clinic to clinic to consult with PAs to satisfy the state's law. It wasn't what the doctor expected when she was a resident, she says.
“She didn't go to medical school to drive a car,” Davis says.
The number of nurse practitioners and physician assistants at work in the U.S. has increased steadily in recent years. A growing proportion of nurse practitioners are staffing physician offices and hospital outpatient clinics, according to the AANP. The group's 2012 membership survey showed 29% of its members worked at physician offices last year, compared with 26.3% in 2009. Another 13.6% worked at hospital outpatient clinics last year, up from 9.4% in 2009.
The group estimates more than 155,000 nurse practitioners currently work in the U.S. The future nurse practitioner workforce is expected to surge to 244,000 by 2025, according to a RAND Corp. projection.
Earning a nurse practitioner's degree is one of the smartest moves in healthcare right now, says Holly Lorenz, chief nursing officer at UPMC health system in Pittsburgh, who agrees that the roles of these nurses will be elevated because of changes that are part of healthcare reform's expansions set to kick in next year and the growing importance of population management. “The nurse practitioner scope of education is a little more broad-based traditionally,” she says.
Lorenz speaks to the strong relationship nurse practitioners have developed with physicians at UPMC. Some of the practitioners are now managing clinics at the system. She also says the evaluation of nurse practitioners compares favorably to the process for physician credentialing. Hospital bylaws and credentialing rules also have the big effect on an NP's role in the inpatient setting, Lorenz says.
Educational requirements for nurse practitioners can vary by state, though the current standard requires a registered nurse to earn a master's degree, which can take an additional three years.
There's been a push by some advocacy groups to require a doctorate in nursing as a requirement for advanced-practice nurses. Eight years ago, the American Association of Colleges of Nursing recommended that all advanced-practice nurses should hold doctorates by 2015. The doctorate is for nurses who want a role in advanced clinical practices or specialties as well as for administration positions. Some physicians worry that nurses who hold doctorates will use the honorific title and cause patient confusion.
A prospective physician assistant needs a bachelor's degree and about three years of specific healthcare experience before entering a PA program, which lasts more than two years, often at traditional medical schools. Students in PA programs follow much of the same curriculum as M.D. candidates, including diagnosis, interpreting test results and counseling patients.
Compared with the push to liberalize laws governing nurse practitioners, there's been less of a battle to loosen state supervision regulations of physician assistants. All 50 states require physician supervision for PAs, but with some variations. Some states define supervision as a telephone conversation, while others require physicians to be on-site for consultation. Other differences by state include prohibitions on dental, hearing or eye exams, as well as limits on prescribing medication.
Wanting a larger role for nurse practitioners doesn't mean the nurses want to become a physician substitute, says Martha Kennedy, an acute-care nurse practitioner at Johns Hopkins Hospital in Baltimore: “I work in surgery, but I'm certainly not a surgeon,” she says.