The next level

As healthcare reform unfolds, midlevel health professionals such as nurses and physician assistants are advocating for more autonomy so they can play a bigger role in the delivery of primary care.

Nurse practitioners, specifically, are pushing hard for more latitude in how they are allowed to provide care. State nursing boards in 16 states and the District of Columbia allow these nurses to practice without physician supervision. The nurses can order diagnostic tests, prescribe medications and manage treatments—among other services—performing many tasks that physicians traditionally provide.

Continued expansion of their roles is one way the industry will treat millions of additional insured patients expected to seek services thanks to the Patient Protection and Affordable Care Act. It's being touted as one answer to the projected shortage of primary-care physicians.

“The sky's the limit for nurse practitioners,” says David Hebert, CEO of the American Association of Nurse Practitioners.

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.

Hebert of the AANP defends the profession from criticism by the medical societies that healthcare quality and treatment outcomes will suffer if nurse practitioners are allowed to take on more clinical and diagnostic procedures traditionally handled by physicians. A larger role for NPs would not only maintain quality, but reduce healthcare costs, he says, adding that the nurses need to have more career freedom and break free of “artificial controls simply in place as a result of lobbying.”

One of the chief detractors, according to Hebert, is the American Medical Association, which has raised concerns for several years over increased autonomy for nurse practitioners.

“New healthcare delivery systems hinge on a team-based approach to care, and physicians are uniquely qualified to lead the healthcare team,” says Dr. Ardis Hoven, president-elect of the AMA. “Policymakers can best serve patients by supporting physician-led, team-based care that optimizes the respective education and training of each member of the healthcare team.”

A 2011 report from the American Academy of Family Physicians also recommends that nurse practitioners should not work independently. Instead, they should heed the AMA's recommendations of working as part of a physician-led care team.

“The AMA advocates that physicians maintain authority for patient care in any team care arrangement to assure patient safety and quality of care,” according to the group's policy statement.

The AMA did acknowledge a growing problem with physicians who don't make themselves available for consultation and supervision, and reminded doctors of the need to make themselves available to midlevel providers.

“People are busy and overstretched; it's not necessarily planned or overt,” says Dr. David Bronson, president of the American College of Physicians. “It's just that M.D.s are busy and nurse practitioners are busy. It's hard to find time for a phone call sometimes, and I think we have to find the time to work together effectively.”

The ACP is particularly worried about providing support to NPs who practice by themselves at retail clinics. “There should also be linkages to ensure that the patient's primary-care physician is notified of any treatment or prescriptions and to assure the availability of continuity of care,” according to an ACP policy.

Physicians shouldn't see nurse practitioners as rivals, Bronson adds. ACP policy calls advanced-practice nursing “a distinctive and complementary profession.” They should embrace the team approach where midlevel providers work with physicians to coordinate and manage patient care, he says.

Many health systems have done well with the team approach involving midlevel health professionals. It's been about 20 years since the Mayo Clinic in Rochester, Minn., first began hiring nurse practitioners for the system's primary-care settings, starting in geriatric-care management, says Dr. Robert Stroebel, associate medical director in the office of population health management for Mayo Clinic Midwest.

Physician assistants and nurse practitioners administer the majority of routine care, which frees up physicians for more-complex and highly specialized cases, and helps pair the right specialty physician with the right patient, he says.

“If a gastroenterologist is seeing a patient with heartburn, and at the same time a person with inflammatory bowel disease can't get in to see a doctor, then your system isn't functioning properly,” Stroebel says.

Physician assistants are also becoming more prominent in the care-team approach. The American Academy of Physician Assistants counts nearly 87,000 PAs working in America and projects employment to rise to 108,300 in 2020. That profession, which like that of nurse practitioner dates to the mid-1960s, was launched to help ex-military medical professionals practice medicine under physician supervision. They share many similar duties that nurse practitioners perform, including performing physical exams, interpreting lab tests and patient counseling. And they are required to operate under the supervision of a physician.

Advocate Medical Group, part of Advocate Health Care based in suburban Chicago, includes more than 1,100 physicians and about 100 nurse practitioners and physician assistants. At the system's hospitals, nurse practitioners can sign off on orders and histories if they've reached a collaborative agreement with a physician—as required by the state of Illinois, says Dr. James Dan, president of physician and ambulatory services for the medical group.

Illinois is a reduced-practice state, according to the AANP. The state allows NPs to practice as primary-care providers, but they can't work autonomously and can't write prescriptions without physician consultation.

One way of boosting physician engagement with midlevel providers is through compensation. Advocate is also dealing with questions over physician pay involving collaboration agreements with nurse practitioners. Physicians could be responsible for the medical malpractice costs in taking on supervision of a nursing practitioner. “That activity needs to compensate for the effort and the risk,” Dan says.

Advocate officials still have to figure out if they should pay physicians for collaborations with nurse practitioners, Dan says. They're also trying to determine if the NPs should be given their own panel of patients, and how many patients that would include. Dan says Advocate still wants to ensure NPs have the “reasonable supervision of a physician.”

Janet Haebler, associate director for state government affairs for the American Nurses Association, downplays the need to reward physicians with extra payments for collaborating with NPs, saying it's just a regular part of a physician's job. She also says the assumed risk isn't as big of a responsibility as it's portrayed. “I'm a registered nurse, not a nurse practitioner, and I have malpractice insurance,” Haebler says.

Dan cites the layer of accountability involved when allowing nurse practitioners to work autonomously. Because of Illinois' regulations on physician supervision, it's difficult to track the patients that nurse practitioners care for. According to the state's rules, the patients are the physician's responsibility under terms of collaboration agreements.

Adding more responsibilities to nurse practitioners and other midlevel providers has been an issue for years. It was noted in the Institute of Medicine's landmark 1999 report, To Err is Human. Citing the need for increased collaboration, the IOM encouraged nurse practitioners to collaborate more with primary-care physicians to reduce medical errors and improve patient care in a team-oriented approach.

Donna Shalala, former HHS secretary and chair of the IOM's Committee on the Future of Nursing, this month commented on the need to expand nurses' roles in the industry. Shalala, speaking at the American College of Healthcare Executives' annual meeting in Chicago, said that turf wars and the notion that primary-care physicians will struggle with finding jobs if nurse practitioners are granted more autonomy “made me want to scream.” She said that type of misinformation prevents nurse practitioners from taking on bigger roles in healthcare, which would benefit the industry.