A Solution to the PCP Shortage: Nurse Practitioners

For me, the solution for our primary care provider (PCP) shortage is relatively simple. Utilize more nurse practitioners (NPs) to manage relatively simple problems and also triage complex patients to physicians (see: Are Doctors Becoming Obsolete? No, But Their Roles Will Be Changing)). By the way, I don't mean to ignore physician assistants (PAs) in this discussion -- they are also part of the solution. Bloomberg Businessweek has now arrived at the same conclusion. Below is an excerpt from a recent article about how NPs are no longer "handmaidens" to physicians (see: Nurse Practitioners, Handmaidens No More):

After years of working with a neurosurgeon and a heart surgeon, nurse practitioner Kathy Kenny opened her own medical practice last year in Chandler, Ariz., where she provides some of the same screenings and treatments that doctors do. Kenny is among 148,000 nurse practitioners who will have to pick up the slack beginning in 2014, if the Supreme Court allows President Barack Obama’s health-care law to add at least 30 million people to U.S. hospital, clinic, and doctors’ practices already suffering a shortage of physicians....The American Medical Association, the nation’s largest physicians’ lobby, opposes allowing anyone to practice medicine independently who hasn’t completed state requirements for medical doctors. Yet by 2015 the U.S. will be facing a shortage of about 63,000 doctors....While there has been a push for more primary-care physicians, training typically takes about 10 to 15 years. Nurse practitioners are registered nurses with advanced degrees and state certifications that can take as few as six years to obtain....Nurses are less expensive than doctors. Medicare, the U.S. health program for the elderly and disabled, reimburses nurse practitioners about 85 percent of what doctors get....The average base salary in 2011 was $91,310. Family doctors make $175,000 to $220,196 a year....The downside to nurse practitioners taking on more of a burden is that often, primary care isn’t simple medicine....Frequently patients have multiple conditions. Without doctors to practice with or good clinical information systems, nurse practitioners alone may be “dangerous,” [according to a physician spokesman]. [Kathy Kenny] says she generally will refer patients to a doctor when they require two or more medications or if someone with Type 2 diabetes fails to respond to insulin and oral medications after two to three months. Certified nurse practitioners can prescribe medication without the supervision of a physician in 16 states and Washington, D.C.

For me and responding to some of the MD quotes in the article, this is a turf battle that the physicians, in the end, cannot win. There will be an inexorable expansion of the privileges of NPs to prescribe medications and practice independently beyond the current 16 states and Washington, D.C. I fully understand that NPs can encounter complex patients whose care may be beyond their expertise. The solution, echoing the quote from Kathy Kenny above, is for them to refer patients who require two or more medications or have complex chronic disease to a physician.

All of this made me curious about the availability and cost of malpractice insurance for NPs. As one might expect, rates are going up. Here's an explanation copied from a Q and A web page of the American College of Nurse Practitioners web site (see: Frequently Asked Questions about NP Liability Insurance):

Nurse Practitioners are being held legally accountable to their scope of practice and now face greater malpractice exposure than ever before, especially in two key areas:

• Diagnostic Responsibilities - Today a great number of NPs are able to work in a collaborative agreement instead of working for a physician in a complementary role.
• Prescriptive Authority - Today NPs can prescribe under their own signature in most states.

With the number and severity of claims against NPs on the rise, rates need to change in order to address two important points: first, the exposure to risk that the class represents and second, the yield of financial return so that the program can sustain itself.

Comments

[Deborah]

My reaction to this is both as a patient, a clinical social worker in private practice, and as the wife of a primary care physcian. Having worked with and watched firsthand, the PCP's complex role, it will be impossible for nurses to deliver the same quality care as doctors. It is a simple fact that the more years of training provide greater insight, perspective and knowledge. As a cancer survivor, it was my own primary care doctor who discovered my thyroid nodule. I came for a check up feeling fine, expecting to be sent home, not to be seen for another year. And finally, as an allied health professional myself in private practice, it has become more difficult to remain in practice with Obama having lowered the reimbursements. So if fewer MD's enter primary care, and the quality of care is lowered, what makes anyone think that nurses will survive any more than the doctors and social workers? It all sounds good for the patients'coverage but with no support from the government, nurses will not survive financially any better than primary care doctors!