Nurse Practitioners as Primary Care Providers
More and more of us are facing this scenario in the doctor’s office: “Your nurse will see you now.”
Wait a minute, you say. “Don’t I deserve to be seen by a real doctor?”
In this issue, we focus on why that very natural reaction is outmoded thinking. Nurse practitioners to many patients are “new” players in health care. Actually, they’ve been around a while. And as more people get more and better health coverage, these highly trained professionals will play a larger role; for some people, they will even serve as primary care providers.
This month we look at who these professionals are and why their expanding role is a good thing for us patients and for the health-care system.
What Is a Nurse Practitioner?
Of all the non-doctor health care providers we patients encounter, the two most important are physician assistants (PA) and nurse practitioners (NP). They have the most education and training, and the most responsibility. They’re quite different from each other, and a little history and background shows why it matters.
Physician assistants are trained under a medical doctor model; nurse practitioners are trained under a nursing model. That makes PAs more science/therapy-oriented, and nurse practitioners more whole-patient oriented.
PAs are licensed to practice medicine with physician supervision. They conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery and in virtually all states may write prescriptions.
Nurse practitioners are registered nurses who have completed graduate-level education and advanced-practice training. Like PAs, they see all kinds of patients, and perform many in-office procedures. They may prescribe medicine, order and interpret tests, admit people to the hospital and discharge them.
Shirie Leng, an anesthesiologist who was a nurse practitioner before she went to medical school, summarized both experiences on KevinMD.com.
Because of their training, she writes, NPs “are more likely to deal successfully with chronic conditions because they will talk to you and listen to you. They don’t have the same time pressures and paperwork blizzards that the doctors have. They’ve been trained by nurses, so they think like nurses, not like doctors. They want to take care of you, not just fix your illness.
“If you have a brain tumor that’s not so helpful, but for the vast majority of everyday health concerns, your nurse practitioner is your friend.”
An Expanding Role
Last year, the National Governors Association reviewed 22 scientific articles to compare treatment by nurse practitioners with that of physicians. Its report, “The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care,” was published in December. The reviewers concluded that “Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures. Moreover, the studies suggest that NPs may provide improved access to care.”
Many of the report’s findings bolster the idea that nurse practitioners can and should assume an even greater role in primary care. Specifically, as summarized by MedPageToday.com:
- NPs provide care that compared with that of physicians in terms of patient satisfaction, time spent with patients, prescribing accuracy and preventive education.
- NPs were capable of successfully managing chronic conditions in patients suffering from high blood pressure, diabetes, and obesity.
- Three analyses found NPs rated favorably in achieving patients’ compliance with recommendations and reductions in blood pressure and blood sugar.
- NPs are more likely to work in underserved urban populations and rural areas.
Because the ACA eliminates co-pays for preventive health-care services, the increased demand for primary care, according to the governors’ report, is expected to increase by 15 to 20 million patient visits per year by the end of this decade. Such an increase in demand would require between 4,000 and 7,000 more physicians, and place an unholy burden on current primary care practitioners because there’s already a shortage of them.
Today, 18 states and the District of Columbia allow NPs to practice and prescribe independently of physician supervision. The other states require some level of physician involvement, but many are considering expanding NP independence. The governors’ report says that’s a good idea.
That’s true especially for primary care’s broad range of services–the initial evaluation of symptoms, ongoing care for chronic diseases, and preventive measures such as immunizations or screenings. According to a policy brief by Health Affairs, the increased availability of primary care is associated with lower mortality and with reductions in emergency department visits and hospitalizations.
Health Affairs reported that nurse practitioners typically are paid less than physicians for providing the same services. Medicare compensates NPs who practice independently at about 85 percent of the physician rate for the same care.
Primary care provided by NPs is less expensive in many cases because they tend to order fewer tests and expensive diagnostic procedures than physicians. So even if their pay was equal to that of physicians, their care would save money for patients and insurers.
With Change Comes Resistance
As you might imagine, some people–mainly doctors–aren’t 100% happy with the expanding the role of nurse practitioners.
The American Academy of Family Physicians (AAFP) has denounced NP-run practices, claiming that the quality of their care isn’t equivalent to that of physician-led practices. Family physicians receive 11 years of training; NPs get five-and-a-half to seven years, says the AAFP. Physicians also must complete about four times more clinical hours than NPs.
But no one is saying nurse practitioners can or should replace physicians, only that they can assume some of their practices with equal or better outcomes, at less cost and with greater patient satisfaction. So are these voices objecting out of concern that they’ll lose patients, and money?
If so, that’s not a legitimate concern, according to the governors’ report: “It is important to note that a recent analysis shows no variation in physician earnings between states that have expanded [the scope of NP] practice laws and states that have not.”
And, according to MedPage Today, a 2010 report from the Institute of Medicine was critical of state laws that prevent NPs and RNs from practicing to their fullest extent.One major health-care provider–Kaiser Permanente–expanded NP roles in a Colorado prenatal clinic and was so pleased with the early results that it’s planning to use the model in more prenatal clinics in that state.
Focus on the Patient
Because getting the right kind of primary care at the right time offers people better long-term health at lower cost, all medical consumers benefit by having a good relationship with a primary care provider. And because the primary care model of comprehensive, patient-centered care traditionally is provided by nurses, we should welcome the expansion of their job description.
If you’re satisfied with your current providers, there’s no reason to change. But if you aren’t, or if your circumstances change, the fact that someone holds the title of nurse practitioner instead of doctor won’t make much difference in the quality of your primary care. And it might even be an improvement.
To your continued health!
Patrick Malone & Associates