I like getting to prevent things
August 9, 2009 -- Nurse practitioners have not received the attention they deserve in connection with the ongoing U.S. health reform debates. But two recent press articles do a generally good job of highlighting the key role NPs play in providing excellent, cost-effective primary care. And the stories suggest that NPs might well play a much bigger role in a health system reformed to increase access to care yet cut costs. Kelly Brewington's lengthy story "Nurse practitioners pick up the slack in providing primary care," which ran in today's Baltimore Sun, gives readers a sense of what NPs already do at a time when fewer physicians are choosing family practice, and suggests that NPs' work might expand if more people had health insurance. And in a July 26 report on National Public Radio's (NPR) Morning Edition, Joseph Shapiro explained the work of transitional care nurses, many of whom are NPs, to help patients navigate the health care system after hospital stays, preventing needless readmissions--and thereby saving a money. Commendably, both pieces rely on expert comment from the nurses, and to a lesser extent several physicians, who actually know about NPs' work, which is not something you can take for granted in media reports about health care areas that overlap with the work of physicians. The Sun does quote a Maryland physician who says NPs are "paraprofessionals" who will actually cost more money through overtreatment. Those comments reflect no understanding of what NPs do or the research showing that their care is at least as effective as that of physicians--a point that the Sun, sadly, did not include. In any case, we commend those responsible for these stories.
The Sun article focuses on the nation's overburdened system of primary care, explaining that as fewer physicians choose to enter that less lucrative practice area, nurse practitioners play an expanding role. The piece uses NP Tricia Angulo-Bartlett, who works with another NP and seven physicians at Seton Medical Group in Catonsville, to illustrate what primary care NPs actually do in a clinical setting. It presents Angulo-Bartlett as being very busy attending to different patients, and suggests that in this respect she is a typical primary care provider. However, NPs generally spend significantly more time with patients than physicians do, which is part of what enables them to be so effective. Indeed, the piece includes a telling comment from a patient who has decided, after experiencing Angulo-Bartlett's care, to see her "exclusively":
She's easy to talk to and sits down and holds a conversation to find out exactly what is wrong with you...She's more than just a doctor - I mean, nurse practitioner.
Of course, that takes time. And although the piece does not link it directly to NP practice, it does get across that spending more time with patients can aid in prevention. It explains that the Seton practice recently became part of a pilot program employing the "medical home" model, which provides funds for more staff and increased use of electronic records to allow providers to devote more time to patients, "with the goal of keeping them healthy and slashing costs." Angulo-Bartlett, who has been at the office for five years, discusses the focus of NP practice:
I like getting to prevent things. I don't want to see you in the hospital when you are having a heart attack. My goal is to see you and prevent it from happening.
She does this by building relationships, finding out whether patients have lost jobs or have family members who are ill. The piece quotes Angulo-Bartlett as saying that "learning why someone might not have the time to exercise four days a week is critical to helping them learn ways to improve their health." Physician Ken Williams, Seton's "president and CEO," adds that the NPs are "very good at patient education. And they have been very effective and popular with patients." The piece also notes that Angulo-Bartlett has bachelor's and masters degrees in nursing from Johns Hopkins (noting that all NPs must have at least masters degrees), as well as a degree in molecular biology from the University of California at Berkeley.
Yet the piece also says that when Angulo-Bartlett "has a question about a complex patient, she consults one of the seven doctors at the practice." This statement, standing alone, is troubling because it will suggest to most readers that physicians simply know more than NPs, and that NPs need more help with "complex patients" than physicians do. And it does not similarly say that when physicians see a patient with a problem outside their area of expertise that they also consult with other health professionals.
Yet the piece itself makes clear some of the ways in which NPs excel, and although it may be that physicians do not consult the NPs about "complex patients" to the same extent the NPs consult physicians, the physicians should. Shouldn't physicians consult NPs about patient education, how to elicit key details about patients' health situation, or the many aspects of care in which nurses generally have greater expertise than physicians do, such as healthy diets for chronic diseases, wound care or breastfeeding? Research shows that NPs are highly effective at managing complex patients, and they also excel at diagnosis because of their advanced interpersonal skills--they find the underlying problems. Some physicians have faulted NPs for too much consultation, and that is the basic argument of Ronald C. Sroka, president of the Maryland medical society MedChi, who appears to think NPs should not exist at all:
That's using paraprofessionals to do a professional's work. They will not save money. We will have more tests performed because of lack of experience and more referrals to specialists. It will cost more.
And we hear they also love death panels! But in fact, consulting with other experts when needed is a hallmark of good practice--something good physicians also do plenty of--and we are aware of no research to support Sroka's uninformed criticism. On the contrary, a great deal of research shows that NP care is at least as effective as that of physicians. Many NPs have years of relevant experience as RNs before they become NPs. And although the piece does not mention it, in 2015 the standard degree for U.S. nurse practitioners will become the doctorate of nursing practice, which will surely be one of the more advanced "paraprofessional" degrees available.
Unfortunately, the response the piece does provide to Sroka's comments is apologetic and weak. The report says that NPs "don't aspire to be doctors" and that "there is a place for various medical professionals when trying to keep patients well." It also quotes University of Maryland nursing instructor Shannon Reedy as saying that many physicians have "wonderful things to say" about NPs, and that anyway, "we don't have a choice," because there are not enough primary care providers.
So NPs are good because "we don't have a choice"? That's pretty compelling, but we might also stress that studies show NP care is at least as good as that of physicians. We might point out that NPs' holistic, preventative focus is ideal for primary care. And we might note that many people--like the patient in this very story--actually prefer NP care.
The article provides some basic background on NPs, noting that the first NP program began in 1965 and that today there are about 125,000 in the U.S. It notes that NPs diagnose, treat, and prescribe, but says that their core mission is different, quoting Reedy, who "co-directs the adult/gerontological nurse practitioner program at the University of Maryland's nursing school":
We still teach [patients] disease management, but we would prefer not to treat disease; we would prefer to keep people healthy. I'm sure many physicians feel the same way, but that is the core of our training as nurses.
The report explains that the rules governing NPs vary by state, but Maryland requires "signed agreements with a doctor specifying their duties and responsibilities." The piece might have explained that this is not required everywhere, and it might have inquired whether NP leaders believe it should be required anywhere. Many do not, and there is likely to be increased pressure to eliminate such requirements as more NPs earn doctorates.
The article also discusses how the role of NPs might expand if health reform leads to coverage for some of the estimated 47 million U.S. residents who are now uninsured. It quotes Reedy:
It's very problematic to make massive health care reform without addressing this issue first. If you add more people to a system that is already burdened, it's only going to burden it more.
The piece says NPs may be well-placed to fill the primary care gap in part because they are "cheaper than doctors to train and pay - Medicare reimburses them at 85 percent of what is paid doctors." Of course, this is double-edged--a selling point, yes, but seemingly unfair to skilled professionals doing comparable work. It might have mentioned that NPs do not join nursing to pursue a mission of unvarnished greed, as many physicians do.
The article also relies on Johns Hopkins Bloomberg School of Public Health professor Jonathan Weiner, who explains that NPs are a key part of health reform proposals, particularly in promoting the "medical home" concept, which emphasizes primary care and prevention as a way to improve health and control costs. On the other hand, the piece explains, some wonder if there will be enough NPs to fill primary care gaps; like physicians, some NPs are now choosing other specialties that pay more.
The generally excellent NPR story focuses on the problem of hospital readmissions, noting that one in five older hospital patients returns to the hospital within a month, costing Medicare $17 billion each year. Reporter Joseph Shapiro notes that many of these readmissions are avoidable:
If you can keep people from returning to the hospital, you get patients who are healthier, government and private insurers save money. But the way our health care system is set up encourages all this waste and the bad health outcomes, too.
The report relies on comments from Stephen Jencks, the "researcher and former Medicare official" who published the study earlier this year from which the readmission figures above are drawn. Jencks reportedly advocates paying up front to coordinate care, arguing that the readmission rate could easily be cut by 15%, and with effort, maybe in half. He says:
We are not in a business where we should have to be accepting this choice that we're either going to have to cut the care we give or we're going to have to accept higher bills. There's a third way of doing it, which is redesigning the care so that we do the things that people want that are effective and that cost less than doing it wrong. Almost anybody can see that if you can keep the patient healthy, the patient is better off and Medicare is better off, and you're delivering the kind of care most people would want to have: win, win, win.
Shapiro says that's why "the issue has gotten the attention of the Obama administration and of policy makers trying to change health care," though he does not say what form that attention has taken. Of course, this preventative "third way" has always been the goal of nursing, though the profession has traditionally lacked the power to make that vision a reality on a large scale.
The piece does describe the Transitional Care Model, a program at the University of Pennsylvania started by Mary Naylor. We commend NPR for identifying Naylor as a "professor of nursing," though since it describes Jencks as "Dr.," it should have done the same for Naylor, who has a PhD and an endowed professorship in gerontology at Penn's nursing school. In any case, Naylor explains the Program:
It's about relationships. The same nurse who begins to work with the patient in the hospital, they become the point person. They become a broker of care for these individuals over time. They only leave them when they think that Mr. Smith or Mrs. Jones is no longer at risk for a poor outcome.
Shapiro explains that in the program, a nurse (usually an NP) follows a patient for about three months. The report commendably notes that "Naylor's studies show the program saves about $5,000 a year for each Medicare patient, largely by keeping them from going back into the hospital." (Nurses do studies!) But the piece also reports that Medicare does not pay for the NPs' work. And of course, Shapiro notes, hospitals aren't making any money from it either.
Most of the report is an illustration of this transitional nurse's role as played by Philadelphia nurse Jessica MacLeod, who works for the Penn program. We hear MacLeod talking to heart patient Ken Rogers, 80, at the home he shares with his wife Peg. MacLeod listens to Rogers's heart (she uses words like "ticker") and asks him questions about his condition. Shapiro says MacLeod first met Rogers when he was in the hospital, coming to see him there every day, then after he went home, she followed up with weekly visits; the one we hear about lasted an hour (!). Shapiro describes this as "kind of like having a good friend come over and hang out, only this friend knows everything about medicine." Very nice. Peg Rogers asks what MacLeod thinks would have caused the atrial fibrillation Rogers apparently suffered. MacLeod explains that many things can cause it, including an illness, an infection, and some medications. MacLeod also attends Rogers's appointments with his cardiologist.
Shapiro notes that MacLeod's focus on helping Rogers manage his care to avoid readmission is not the way it has worked for him in the past, and we hear a telling exchange between nurse and patient.
Mr. ROGERS: Usually when - before this when I came out of the hospital, you go, yeah? What do I do now?
Ms. MACLEOD: Yeah.
Mr. ROGERS: You know what I mean?
Ms. MACLEOD: Yeah.
Mr. ROGERS: It was (kissing sound) see ya.
And Shapiro gives MacLeod room to explain what she and her program offer in the current health care system.
Mr. and Mrs. Rogers I would consider very smart and savvy people, and assertive. And even having those skills, health care is complex, and we have a health care system that is increasingly complicated. And, you know, if you've ever been to the doctor's office yourself, you are hearing words for the first time, and they're maybe said once. And it's hard to get a word in edgewise sometimes and say, wait, what is atrial fibrillation, doc? You know, what does that mean? So part of my job is a translator, really, and I translate the language of health care to a lay person's language.
In fact, that is a key role of all nurses, one that can make the difference between a patient staying healthy and getting sick. Obviously, nurses should have the time and the resources to play the role, and to manage their patients' conditions, both to enhance health and to save resources.
We commend those responsible for both of these news reports, which illustrate the value of NPs in a complex and troubled health care system.
See the article "Nurse practitioners pick up the slack in providing primary care: Health care reform, bringing with it more covered by insurance, expected to increase need" by Kelly Brewington in the August 9, 2009 edition of the Baltimore Sun. You can send the author emails at firstname.lastname@example.org. Please copy us on your letters at email@example.com. Thank you.
Listen to the story "Transitional Care Cuts Hospital Re-Entry Rates, Costs" by Joseph Shapiro aired on July 28, 2009 on National Public Radio. Write to the author at:
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