What's New? ..... thoughts on NPs in Primary care

While catching up on my readings, the photograph of a painting on the cover of the American Journal Of Nursing January 2014 issue caught my attention. The painting portrayed a boy standing on a chair and trying to decipher the words on a framed Diploma/certificate of a NURSE PRACTITIONER hanging on the wall - while he was pulling up his bridges after being examined by the Nurse Practitioner . This picture provided the food for thoughts for this week's "WHAT"S NEW".


Many of you may have been asked by friends and families as to why you want to bring your children to a nurse practitioner rather than a physician for his/her primary care. This issue is a device one among health care providers. Some call it TURF protection. I have copied an articles for your review....


Nurse Practitioners and Primary Care

EDITOR'S NOTE: An udated brief was published May 15, 2013.

Federal and state laws and other policies limit how these professionals can help meet the growing need for primary care.


What's the issue?

Nurse practitioners are a type of advanced-practice registered nurse. They are registered nurses who have also obtained a postgraduate nursing degree, typically a master's. So-called scope-of-practice laws in many states give these professionals the ability to perform a wide range of primary care services that may be offered when people make an initial approach to a doctor or nurse for treatment as well as ongoing care for chronic diseases.

With a predicted shortage of primary care as the population grows and as millions of people become newly insured starting in 2014, one proposed solution is to expand the role of nurse practitioners in many more areas of the country, and to allow them to provide a wider range of preventive and acute health care services.

Some physician groups oppose an expansion of nurse practitioners' scope of practice, citing concerns over patient safety. Much of the controversy plays out in state capitals, where medical boards and legislators determine scope of practice for nonphysicians, including nurse practitioners. There are also considerations at the federal level that bear on nurse practitioners' ability to be reimbursed for the care that they provide.

This brief examines the policy proposals for allowing nurse practitioners to practice to their full potential and the accompanying debate.


What's the background?

Primary care comprises a broad range of services, including the initial evaluation of new symptoms, ongoing care for chronic diseases, and preventive services such as immunizations or screenings. The increased availability of primary care is associated with lower mortality and with reductions in emergency department visits and hospitalizations.

PROVIDING PRIMARY CARE: Primary care services can be provided by physicians and by a range of nonphysician practitioners, such as physician assistants and nurse practitioners, both of whom have graduate degrees and are authorized to examine, diagnose, and treat patients. Although physician assistants must practice in association with a physician, state law determines whether nurse practitioners can work independently of a physician.

In 2012, 18 states and the District of Columbia allowed nurse practitioners to diagnose and treat patients and prescribe medications without a physician's involvement, while 32 states required physician involvement to diagnose and treat or prescribe medications, or both .


Many Americans have insufficient access to primary care. The Health Resources and Services Administration (HRSA)--the federal agency responsible for improving access to health care services for people who are uninsured, isolated, or medically vulnerable--has identified roughly 5,700 geographic areas containing 55 million residents as being Primary Care Health Professional Shortage Areas. These areas would need more than 15,000 additional practitioners to meet the target ratio of one primary care practitioner for every 2,000 residents.


Primary care shortages may increase in the future because of changes in demographics (growth and aging of the US population) and demand because of increased insurance coverage with the full implementation of the Affordable Care Act. Many of the initiatives to improve access to primary care focus on increasing the capacity to provide services by increasing the supply of primary care practitioners, often physicians.


PHYSICIANS AND PRIMARY CARE: For more than a decade, there has been reduced interest in primary care among new medical graduates. There are many reasons for this, including physician payment systems that pay more for specialty care than for primary care. In addition, some observers argue that physicians are overqualified for some of today's primary care work, which can involve routine physical assessments and ongoing care rather than diagnosis and treatment of complex conditions.

Some policy makers want to make primary care more appealing to new physicians by increasing payments for primary care services or by supporting loan forgiveness programs for physicians who practice in underserved areas. However, policies intended to encourage future doctors to specialize in primary care will probably require a long time before having a significant impact on capacity. Even then, there is no guarantee that new primary care physicians will continue to practice in the field. Others believe that the emphasis should be on restructuring the delivery of primary care (see "New Models" below).


NURSE PRACTITIONERS AND PRIMARY CARE: There is a growing body of research demonstrating that patients perceive that receiving primary care and having a usual source of care is more important than who it was that provided these services. Studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar. For example, a systematic review of 26 studies published since 2000 found that health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians.

What's more, patients seeing nurse practitioners were also found to have higher levels of satisfaction with their care. Studies found that nurse practitioners do better than physicians on measures related to patient follow up; time spent in consultations; and provision of screening, assessment, and counseling services. The patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.

Advocates also note that nurse practitioners could fill the growing primary care shortage more quickly than could physicians, since it takes nurses on average 6 years to complete their education and training, including undergraduate and graduate degrees, compared to an average of 11 to 12 years for physicians, including schooling and residency training.

As noted, state scope-of-practice laws determine which functions different professions can perform and in what context. Medical practice acts in every state give physicians full authority to diagnose and treat all conditions. In contrast, nurse practitioner authority varies significantly, with some states allowing nurses to practice independently from physicians, while others require them to be supervised by physicians. Most states fall somewhere in between, requiring nurse practitioners to collaborate with physicians, particularly when prescribing drugs.

Nurse practitioners are nearly always paid less than physicians for providing the same services. Medicare pays nurse practitioners practicing independently 85 percent of the physician rate for the same services. The Medicare Payment Advisory Commission, the federal agency that advises Congress on Medicare issues, found that there was no analytical foundation for this difference. But revising the payment methodology would require Congress to change the Medicare law. Doing so, however, could increase total Medicare spending if increased payment rates are not offset by savings in other areas.

There is evidence that primary care by nurse practitioners is less costly because they tend to order fewer tests and expensive diagnostic procedures than do physicians. Thus, there still may be cost savings from nurse practitioners even if they are paid on a par with physicians for the same services.

In addition, Medicaid fee-for-service programs pay certified pediatric and family practice nurse practitioners directly, but these rates vary by state. Some states pay nurses the same rates as they pay physicians for some or all services, but more than half of the states pay nurse practitioners a smaller percentage of physician rates. The Affordable Care Act provides for enhanced Medicaid payment for primary care services furnished by physicians, and an Institute of Medicine (IOM) report recommended Congress apply those same rates to nurse practitioners providing similar primary care services.

Health insurance plans have significant discretion to determine what services they cover and which providers they recognize. Not all plans cover nurse practitioner services. In addition, many managed care plans require enrollees to designate a primary care provider but do not always recognize nurse practitioners as primary care providers. A survey by the National Nursing Centers Consortium found that in 2009, nearly half of the major managed care organizations did not credential nurse practitioners as primary care providers. Lack of credentialing is cited as a particular problem for Medicare and Medicaid managed care plans, because a growing percentage of the population covered under both programs is enrolled in managed care..........................................................                            http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=79